Against Medical Advisement Form printable pdf download

Against Medical Advisement Form

Against Medical Advisement Form (AMA Form)

I, _____________________________, being the owner/guardian of _____________________, wish to

have surgery performed on him/her against the medical advisement of the veterinarian on staff. The

veterinarian on staff has advised me that it is in my pet’s best interest to be referred to a full service

clinic for the reason(s) listed below. Although Dehart Veterinary Services, PLLC. has surgery protocols

that operate under a high standard of care, they do not offer diagnostic services that my pet may

benefit from prior to undergoing surgery. I do, however, understand that changes to Dehart Veterinary

Services, PLLC. surgery protocols will be made, when possible, to adjust to the health condition(s) of my

pet. By signing this statement I fully understand the possible complications, including death, that can

arise from my pet having surgery under the conditions available at Dehart Veterinary Services, PLLC. and

I will not hold them or the veterinarian on staff liable for any complications that are related to the

condition(s) listed below.

Condition(s):

________________________________

________________________

Pet Owner

Date

_______________________________

_______________________

Veterinarian on Staff

Date

______________________________

______________________

Witness

Date

Against Medical Advisement Form