"*" indicates required fields CommentsThis field is for validation purposes and should be left unchanged.Owner DetailsName* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone*Patient InformationPatient Name*Species*Breed*Sex* Male Female Age*Weight*The Freestyle Libre Glucose Monitor is a medical device created and FDA approved for human use for monitoring glucose levels in diabetic patients. Though neither this device nor any other similar device has been approved for pet use, veterinary specialists recommend pet owners to use the Freestyle Libre for their pets off-label. At CAMC, we recommend Freestyle Libre Sensors as they are much more comfortable for the pet versus sticking them multiple times to get blood samples to perform a traditional blood glucose curve. Pros: More convenient and comfortable to read pet's glucose levels Allows readings to be taken at home in the pet's regular environment which minimizes stress induced elevated glucose levels. 3) Because you are able to get readings at home, they tend to be more indicative or your pet's normal levels and consequently more accurate for adjusting medications than having to bring your pet to CAMC for a traditional blood glucose curve. Can be worn up to two weeks to monitor glucose levels for that time period instead of just a daily glucose curve at CAMC. Cons: Not approved for pet use. Because it is designed for human skin, the sensors sometimes do not stick the entire two weeks. Our doctors usually shave the application site and add tissue glue to the adhesive pad to help them stick to your pet, but that does not guarantee it will stick for the entire two-week period. Our doctors reccomend that your pet wear a t-shirt and/or an elizabethan collar to keep your pet from licking or chewing at the sensor. The t-shirt also helps prevent the pet from rubbing against something to get it off (the sensor is not painful in any way, but it does feel different than normal to some pets). As with other techological devices, on occassion these sensors fail in less than 2 weeks, and because it is used on a pet, the manufacturer does not guarantee the device. Note: With human use, if the sensor falls off or stops working prior to the two week period, the person must call Abbott, tell them what happened and where the sensor was located on the person's body (the only warranted placement is on the back of the upper part of the arm), and Abbott will send a replacement sensor at no charge. If your pet's sensor malfunctions, it will be your choice if you call them and say you were using the device on the back of your upper arm and it stopped working to get a replacement. CAMC is not able to contact the manufacturer directly.Consent* I understand that once this sensor is applied at CAMC, CAMC does not give a guarantee or warranty that it will function or stay in place. Once your pet leaves the practice, if the device fails or falls off, you accept responsibility to follow up with the manufacturer to seek a possible replacement.Consent* I understand that no refunds or credits will be given by CAMC for early failure of the device or if falls off.Consent* I have read and agree with these terms, and I would like the CAMC doctor to apply a Freestyle Libre Sensor to my pet today.Client Name* First Last Client Signature*
