Client Refusal to Authorize and/or Pay for
Recommended Behavior Modification or Sedation for Behavior-related
Handling Issues
(Place your logo hospital contact info and logo up here)
Client’s name ______________________________
Name of Pet _______________________________
Species ___________________________________
Breed ____________________________________
I, the undersigned owner of the pet(s) identified above, being 18 years of age or older, am
authorized to make decisions regarding its case.
I hereby acknowledge that my veterinarian has recommended or offered behavior modification
and/or sedation of my pet for handling-related issues so that he/she can be performed in the least
stressful manner for my pet.
I decline these recommendations (circle the ones offered that you decline)


Sedation
Technician behavior modification sessions.
I understand that because my pet is fearful or otherwise resistant to these procedures, that by
declining these services the veterinary staff will be required to use force to restrain my pet and
that he/she is likely to react by struggling and possibly showing aggression.
Such an event can heighten fear in my pet and the fear can progress now or in the future to
aggression.
I agree to hold the doctors and staff at this practice harmless for any adverse behavioral effects
that result.
_________________________________________________
Signature of Owner or Authorized Agent
___________________
Date