I, being responsible for the above-described animal, have the authority to grant Dr. Goldman my consent to assess, make recommendations for, and, in some cases, treat the animal.
Dr. Goldman will use all reasonable precautions against injury or illness but will not be held liable or responsible in any manner whatever on account of the animal or otherwise in connection therewith as it is understood that I assume all risks. I understand that the behavior of animals is sometimes unpredictable and that some animals are capable of inflicting serious personal injury or death, as well as significant property damage. I acknowledge that while Dr. Goldman will take every reasonable precaution to minimize the potential of danger posed by the animal, it is never possible to guarantee the temperament and/or behavior of any animal at all times and under all circumstances.
In consideration of evaluation, I hereby agree that I assume all responsibility for the death, personal injury or property damage that may be sustained as a result of or in connection with the evaluation. I agree to forever release, discharge, indemnify and hold harmless Dr. Goldman from any and all claims, damages and liability to me or to any person claiming under, through or on behalf of me, arising out of or connected in any way with the animal(s)’ participation in the evaluation.
I acknowledge that no assurance or guaranty has been made of the results of treatment and that all risks and probabilities complications exist. I warrant that I have the right to enter this agreement.
I represent that I am over 18 years of age.
I HAVE READ THIS AGREEMENT CAREFULLY AND FULLY UNDERSTAND ITS CONTENTS. I AM AWARE THAT THIS IS A WAIVER, RELEASE OF LIABILITY AND INDEMNITY AGREEMENT, AND AN ENFORCEABLE CONTRACT BETWEEN DR. GOLDMAN AND I, AND I SIGN OF MY OWN FREE WILL.
This release shall be binding upon me and my heirs, legal representatives, and assigns.
Veterinarian: ________________________________________________________________________ Tel. No.: __________________________________
Address: ___________________________________________________________________________ E-Mail: ___________________________________