Prescription Waiver Form

Save time getting your pet’s medication by completing your required prescription waiver form online.

Prescription Waiver Form

Please complete the form fields below and we will be happy to call you directly to collect further information.
OR
Download, print, and complete form with required client/patient information and bring to your appointment.

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Prescription Policy

Prescription Waiver Third Party Pharmacies

Waiver of Responsibility and Liability for Prescriptions chosen to be filled with pharmacy or other store not associated with Wolf River Veterinary Clinic or the Midwest Veterinary Supply Pharmacy.

Client to check each box. Waiver required for each pet prescription.

There is a possibility drugs purchased elsewhere may be counterfeit, not approved by the FDA, and could harm or kill my pet. Drugs from third-party sites may not have been stored properly, out of date, repackaged/falsely packaged, or improper drugs. See FDA website for more information.
Purchases from online/third party sites may not appear in my pet’s medical records and may complicate their health care.
Product warranties for prescriptions obtained elsewhere may be null and void.
Prescriptions purchased elsewhere may be incorrect numbers of tablets or capsules, incorrect milligram unit sizes, volume and/or concentration of liquid, and not match my pet’s veterinary directions.
Manufacturer rebates/discounts that are ordinarily available for use through the clinic may not be available.
The manufacturer’s guarantee for products may not be available. If your pet’s condition is not treated or there are complications with treatment, manufacturers may not support your pet’s care.
I hereby request a written prescription for medication or food for my pet so that I am able to purchase these products from a third party pharmacy or online/internet.
By signing this waiver, I acknowledge that I have been informed of potential risks involved in doing so, and I accept any and all responsibility financial or otherwise, that may occur from this decision.
I agree and release all liability of Wolf River Veterinary Clinic, including its veterinary and staff, from any personal or professional liability with third party pharmacies

I, the undersigned, have read the above statements and do fully understand the risks involved in purchasing prescription medication and/or prescription food from a place other than a veterinary clinic and against the advice of medical staff. Due to my decision to purchase prescription items from somewhere other than a veterinary clinic, I have been informed that there may be complications involved in buying items elsewhere. By signing this form, I release all liability of Wolf River Veterinary Clinic of any responsibility in regards to my decision.

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Prescription Waiver Form

Prescription Waiver Form

Prescription Waiver Third Party Pharmacies

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