Meridian Mobile Veterinary Care PLLC
Clients Name: ____________________________________
Patient’s Name: ___________________________________
I certify that I am the owner or authorized agent for the owner of the patient listed above. I also certify that I am over the age of eighteen.
I understand that the goal of hospice care is to help my pet live life as fully as possible until the time of death (with or with out intervention). This can involve pain management strategies, nursing care, alternative therapies such as acupuncture, nutritional guidance, and recommendations for ancillary care providers. The goal of hospice care is to support, not to cure.
I have been informed of my pet’s diagnosis and prognosis. Other diagnostic and treatment options (if available) have been explained to me. I am electing not to pursue these options and to enter into a hospice plan with Meridian Mobile Veterinary Care PLLC.
I understand that, in order to provide my pet with the best possible care, Meridian Mobile Veterinary Care PLLC must be fully informed about my pet’s diagnosis, medical history, and current medications. I authorize Meridian Mobile Veterinary Care PLLC to communicate with and coordinate care with my primary veterinary clinic:
I am aware that Meridian Mobile Veterinary Care PLLC is capable of providing acupuncture, hospice care, and end-of-life services only. In the event that my pet needs additional diagnostics or care (including radiographs, blood work, surgery, and emergency care), I can return to my primary veterinarian or accept a referral to either a specialty/emergency hospital or to Meridian Mobile Veterinary Care PLLC’s clinic partner.
I acknowledge that every animal is unique and responds differently to care. No guarantee has been made concerning the length or quality of my pet’s life while in hospice care.
In the absence of negligence, I agree to hold Meridian Mobile Veterinary Care PLLC, its veterinarians, agents, and representatives harmless for the lack of response to treatment or to any ill effects experienced by my pet while in hospice care.
I understand that any recommended service providers, such as pet sitters and grief counselors, are independent entities. I release Meridian Mobile Veterinary Care PLLC, its doctors, agents, and representatives from any liability concerning the use of these service providers.
I acknowledge that Meridian Mobile Veterinary Care PLLC does not allow any photography or video recording while my pet is receiving care.
I understand that it is my responsibility to properly use, store, and dispose of any hospice medications or supplies left in my home.
I certify that the concept, goals, and logistics of hospice care have been explained to my satisfaction and that any questions that I may have had have been answered.
Signature: ________________________________________________________________________ Date: ______________