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Heartworm Test Waiver
Pet owner name
*
Pet name
*
Primary phone number
*
Please review the following information before continuing to the next page.
Preventive Care Waiver
-I understand that my dog/cat is at risk to contract heartworm disease.
-I understand that if heart worm disease is contracted it could be fatal.
-I understand that treatment for heart worm disease is not guaranteed and can cost up to $1,000 or more.
*
My veterinarian's recommendation is
I herby decline
*
I herby decline
Heartworm Test
Heartworm Preventive
I hold both veterinarian and staff harmless should illness, injury, or death result from declining the recommended care.
Pet Name
*
Veterinarian
*
Pet Owner's Name
*
Pet Owner's Signature
*
Signature
*
Submit
