Heartworm Wavier Form

Please complete the Heartworm Waiver Form to acknowledge recommended testing and provide your informed consent.

Heartworm Wavier Form

Please complete this form as accurately as possible to acknowledge the recommended heartworm testing and provide your informed consent.

Owner / Authorized Agent: *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Pet's Name *

Species *

Breed *

Date of Birth *

Sex *

Color / Description *

Treatment(s) or Test(s) Recommended:

I understand that it is best for my pet to have a heartworm test prior to refill on heartworm preventative. Infected dogs placed on heartworm preventative can have damage to the heart.

Treatment(s) or Test(s) Statement:

As owner or authorized agent of the owner of the animal described above, I have decided not to proceed with the treatment(s), vaccines or test(s) recommended above. The reasons for the procedures/vaccines have been fully explained to me as well as the risks inherent in not proceeding with them. In making this decision I agree to absolve 4 Paws Veterinary Care, Dr. Lisa Wiggins and the staff employed by the practice of any responsibility for the consequences of this decision. I have read and understand this waiver and I am over the age of eighteen.

Name *

First

Last

Signature *

Clear Signature

(Signature) I certify that if I am signing as an agent, I have the authority to execute this consent.

Date *

Witness *

Date *

Name

Heartworm Wavier Form