Against Medical Advice Acknowledgment

  • MM slash DD slash YYYY
  • Acknowledgement

    An Animal Eye Care ophthalmologist has recommended a specific course of therapy, method of treatment or a means diagnosing and/or treating a medical condition for the patient named above. This decision is a medical decision that is made by the doctor based upon the findings of an examination and/or diagnostic testing. The doctor believes this recommendation is in the patient’s best interest.
  • The patient’s owner has elected not to follow the recommendations of the doctor as noted above and accepts responsibility for any consequences of that decision. The risks of not following the doctor’s recommendations have been fully explained to the patient’s owner by the doctor. The patient’s owner agrees that the doctor or Animal Eye Care shall not be held responsible or legally liable for the decision or any future consequences of the patient’s owner’s decision.
  • By signing below the patient’s owner acknowledges that s/he has read this information and has elected not to follow the doctor’s recommendations.