Practice name, address, phone, website
Client Consent for
Veterinary Peptide Therapy
Complete one form per peptide prescribed. A signed copy is retained in the patient record and a copy is provided to the owner.
PATIENT
Name
Species, breed, sex, age, weight, BCS
OWNER
Name
Client ID, phone
PRESCRIBED PEPTIDE
Peptide and vial strength
Class or mechanism, lot number
DOSE / ROUTE / FREQUENCY
Dose, route, frequency
Titration plan, date prescribed
Owner acknowledgements
I understand that this therapy is being provided under a veterinarian-client-patient relationship and may be used off-label.
I understand the expected benefits, risks, and alternatives have been discussed, and no guarantee of outcome has been made.
I agree to give the medication exactly as directed and to report any adverse effects promptly.
I understand the medication is intended only for the named animal and will not be shared.
Owner signature
Date
Veterinarian signature
Date
PRACTICE NAME · CITY, STATE
Retain signed original in patient record · Form PEP-1