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Heartworm Preventative Waiver

I understand that my dog/cat is at risk to contract heartworm disease.
I understand that if heartworm disease is contracted it could be fatal.
I understand that treatment for heartworm disease is not guaranteed and can cost up to $1,000 or more.

My Veterinarian’s Recommendation is:(Required)

Client's Phone Number(Required)

I herby decline(Required)

Heartworm test

Heartworm preventive

I hold both veterinarian and staff harmless should illness, injury, or death result from declining the recommended care.

Pet Name(Required)

Veterinarian

Pet Owner's Name(Required)

Date(Required)

Pet Owner's Signature(Required)

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