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Against Medical Advice (AMA) Form

Sugar Land Veterinary Clinic

Name

Cell Phone Number

Email Address

Pet's Name

Name if acting in place of the owner

Authorization

I am electing to decline the recommended treatments as the owner of the pet named above. I understand that in doing so, I am taking the possible risks for my pet's health, including, but not limited to: pain, suffering, and even death. I have had the opportunity to ask questions to try to get to a resolution, and I understand my pet’s medical condition as well as the risks and possible outcomes that can occur by not seeking treatment for my pet at this immediate time.

As I have been informed, signing this waives Sugar Land Veterinary Clinic (SLVC) of all responsibility, should the above-named pet‘s health status decline further. Signing this form does not prevent me from returning to Sugar Land Veterinary Clinic, should I decide to pursue further treatment for my pet.

The need/nature of this form has been discussed with me, and I have no further questions at this time.