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MAPS Consent Form
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Owner's Legal Name
Owner's Date of Birth
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Driver's License Number
I am the owner or the agent for the owner of the animal described above, and I have the authority to execute this consent.
I have been informed that my animal requires a prescription of a Schedule 2-5 Controlled Substance that exceeds a 3-day supply. Under Public Act 248 of 2017, in order to obtain this prescription, the veterinarian or designee must run a report through MAPS, Michigan’s prescription monitoring program. This law requires prescribers to obtain and review a patient’s prescription history for red flags and signs of potential opioid abuse prior to prescribing a controlled substance. Kibby Park Animal Hospital will check MAPS reports for all new prescriptions and for patient use of chronic medications (maximum of every 90 days); we will check reports as dictated by Michigan law.
This facility follows all HIPAA privacy regulations. The MAPS report will not be transferred, received, handled, or shared. It will be used as a reference to review history of your animals’ medications only, in accordance of the law.
This consent form is valid for 12 months.
Please type your full name to sign this consent form.
I Confirm That I Have Read and Agree to This Consent Form