Waiver For Written Prescription Form

I hereby request a prescription for the medication(s) for my pet so that I can
purchase these products from an internet pharmacy or catalog vendor. I have been
informed that the following risks exist when I obtain these products from such
sources.

1. There is a possibility that the prescription drugs received from these vendors
   may be counterfeit and may not have been approved by the Food and Drug
   Administration (FDA), United States Department of Agriculture (USDA) or the
   United States Environmental Protection Agency (EPA).
2. As the provider of your pet’s care, our medical records keep track of all drugs
   dispensed by Strong Veterinary Hospital to you. When you purchase your
   prescription elsewhere, our computer tracking system is not activated to print
   instructions for use, risks of adverse effects, or to send reminders for follow
   up exams and/or lab tests that may be needed to monitor results or adverse
   effects.
3. You may not have the prescription drug(s) available soon enough to start
   your pet’s medications at the optimal time to provide relief for his/her
   condition.
4. When prescriptions products are purchased elsewhere, our staff members are
   unavailable to teach you how to administer these medications.
5. The number of tablets/capsules, milligram strength, size of the unit, volume
   and/or concentration of the liquid and number of authorized refills may differ
   from prescribed by the attending doctor.
6. Manufacturer rebates that would ordinarily be available for products
   purchased from Strong Veterinary Hospital generally will not be available.
7. The manufacturer’s warranties or guarantees for these products may not be
   valid. This means if your pet’s conditions are not effectively treated with the
   product(s), manufacturers may not stand behind their products or product
   liability procedures. Additionally, the doctors and staff of Strong Veterinary
   Hospital will be unable to assist you in claims against the manufacturers.
8. By obtaining a written prescription to send to these online pharmacies or
   catalog vendors, Strong Veterinary Hospital is no longer responsible for that
   written prescription. If the written prescription is lost or rejected from the
   online pharmacy or catalog vendor, a new written prescription potentially will
   not be issued.

I have read and understand the above, accept these risk, and am aware that Strong
Veterinary Hospital cannot accept any financial responsibility for paying for or
reimbursing me for any treatments required because of the use of products purchased from these sources. In the absence of negligence, I agree
to hold Strong Veterinary Hospital harmless for any deleterious effects or lack of
effectiveness of prescription medication or prescription food purchased from any
other source.