Page 1 of 1

E-collar Against Medical Advice Release Form

Locust Valley Veterinary Clinic

280 Forest Ave

Locust Valley, NY 11560-2150

United States

(516) 676-6161

Client Full Name:

Phone #:

Patient Name:

Authorization

Please read and sign below:

I, the undersigned owner or authorized agent, have been advised by a licensed veterinarian at Locust Valley Veterinary Clinic that my pet should wear an Elizabethan collar (e-collar) for post-operative or post treatment care. The e-collar is recommended for the following reasons:

- To prevent licking, chewing, or biting at a surgical incision.

- To prevent interference with wound healing.

- To prevent a bandage or sutures from being removed.

- To prevent self-trauma to the face, eyes, or head.

- To prevent the spread of infection or bacteria to the wound.

The following potential complications have been explained to me if my pet is not prevented from interfering with it’s recovery site:

- Infection of the incision or wound.

- Suture or staple removal, which can lead to the incision reopening (dehiscence).

- Additional injury or trauma to the wound or surrounding tissue.

- Increased inflammation and swelling.

- Possible need for additional surgery, treatments, or hospitalization, which would incur additional costs.

- Prolonged healing time.

Despite the medical advice and explanation of risks, I hereby decline the use of an e-collar for my pet.

I acknowledge and accept full responsibility for any and all adverse medical problems or outcomes, including potential death, that may arise from my decision to refuse recommended medical advice. I itsany corrective measures needed.

I voluntarily and knowingly release Locust Valley Veterinary Clinic, it’s veterinarians, staff, and agents from all responsibility, liability, claims, or damages that may result from my refusal to follow their medical advice.

Signature of Owner or Authorized Agent: