&bs&es&pname&ef&bf                                                           
&pad1                                                                        
&pad2                                                                        
&pad3                                                                        
                                                                             
                                                                             
                                                                             
           CONSENT FOR USE OF UNLICENSED PRODUCT FOR &animal    (&ref)       
                                                                             
&client                                   &breed                             
&address1                                 &age                               
&address2                                 &sex                               
&address3                                                                    
                                                                             
                                                                             
I understand that ........................................is a               
                                                                             
product that is not licensed for use in ......................               
                                                                             
but it is acknowledged as a product useful in the treatment of               
                                                                             
............................... I have also been made aware of               
                                                                             
the possibility of side effects and of the precautions related               
                                                                             
to its administration.  In accepting its use for &animal,                    
                                                                             
I accept any attendant risks.                                                
                                                                             
                                                                             
                                                                             
                                                                             
                                                                             
Signed ..................................                                    
                          &client                       &date                
                                                                             
                                                                             
.pa