Client Refusal to Authorize and/or Pay for

Recommended Behavior Modification or Veterinary Behaviorist Referral

Nutz About Mutz! (Jody Epstein, CPDT-KA)

 

 

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 trainer, Nutz About Mutz! and Jody Epstein, has recommended or offered management options, behavior modification and/or referral to a veterinary behaviorist for my pet’s handling-related or behavior-related issues.

 

I decline these recommendations (circle the ones offered that you decline)

 

• Management In Home and/or In Public (e.g. barriers, basket muzzles, etc)

• Behavior Modification

• Veterinary Behaviorist Referral

 

_____ I understand my pet is showing aggressive tendencies (including, but not limited to: resource guarding, fear-aggression, or status-related aggression) and behavior displays including, but not limited to: cowering, trying to escape, growling, showing teeth, snarling, fixated focus, snapping, lunging, biting and other stress related behaviors.

 

____ I understand that by declining the above recommended services the current behavior issues are likely to escalate and a major bite incident may occur.

 

_____ Continued opportunity to practice escalating aggressive behaviors (e.g. growls, barks, fixated focus, lunges, snaps, bites) will raise my dog’s base line arousal for such behavior, causing her/him to trigger more easily and become more aggressive, possibly without warning prior to a bite.

 

_____ I agree to hold Nutz About Mutz! and Jody Epstein harmless for any adverse behavioral effects that result from declining these services.

 

_____ I agree that I, the legal guardian of the above named dog(s), shall be held solely and completely financially responsible for any damage or injury to a human, another animal or property that incurs a cost to repair.

 

 

 

   _________________________________________________                   ___________________

            Signature of Owner or Authorized Agent                                             Date