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BACK TO WEBSITE
Client Forms
Arrival Check-in
New Patient Form
Prescription Refill
Client Survey
Pay Online
(210) 651-1384
3929 Cibolo Valley Dr., Suite 200,
Cibolo, TX, 78108
Arrival Check-In
Pay Online
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
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Phone number where you can be reached TODAY (Very Important)
*
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