Heartworm Treatment Release Form

All required fields are marked {*}

Client Information
Client Name:*
First Last
Today's Date:*
MM slash DD slash YYYY
Client Email:*
Patient Name:*
Color:*
Sex:*
- Male
- Female
Spayed/Neutered?*
- Yes
- No
Age:*
Breed:*
I authorize the performance of the following procedure(s):*
Is your pet currently on a special diet (including treats)?*
- Yes
- No
If "Yes" above please explain:
Has your pet had any medications in the last 24 hours (including non-prescription medication or supplements)?*
- Yes
- No
If "Yes" above please explain:
Included in the heartworm treatment package is: A complete physical exam, pre-treatment bloodwork, radiographs, immiticide injections (Based on the weight of the animal), steroid injection(s), and three days of boarding.
Do you need a refill on heartworm, flea, and tick prevention?*
- Yes
- No
If "Yes" above which preventative do you need and how much would you like?
Please list any vaccinations your pet is currently due for: (If they are up to date please say None)*
I Authorize*
Do we have your authorization to bring them up to date on their shots?
• Did your pet having any coughing which required a steroid to treat?*
- Yes
- No
If "Yes" above please explain
If your pet has received the first melarsomine injection, did they have any back pain that required medication?*
- Yes
- No
I Understand and Accept*
I understand that while the treatment used in this hospital is one of the safest used in veterinary medicine, NO treatment is without medical risks. No guarantee can be made legally or ethically to me on the outcome of any procedure performed. Any complications arising from the above procedure will charge for at time of recheck visit.
Name*
First Last
Signature*
Phone number where you can be reached TODAY (Very Important)*
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Email
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Heartworm Treatment Release Form

Client Information