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Heartworm Test Waiver Form

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Client Information

First Name*

Last Name*

Pet's Name

DOB/Age*

Species*

Cat

Dog

Breed*

Color*

Weight*

Address*

Street Address

Address Line 2

City

State

ZIP Code

Phone*

Email*

Heartworm Test Explanation:Heartworm disease is a severe and potentially lifethreatening condition that affects dogs and, less commonly, cats. It is transmitted
through mosquito bites and can be challenging to detect in its early stages. Regular
heartworm testing is crucial for early diagnosis and treatment, which can be
lifesaving for your pet.

Heartworm Preventative Medication:
Heartworm preventative medications are
available and effective in protecting pets from heartworm disease when
administered correctly and consistently. These medications do not treat existing
infections but can help prevent new infections from developing.

I, the undersigned client, understand and agree as follows:

I have been informed about the importance of heartworm testing and
understand the risks associated with declining a heartworm test for my pet.
I acknowledge that my pet may be at risk of heartworm disease if not tested
regularly.
I have chosen to decline a heartworm test for my pet but wish to purchase
heartworm preventative medication for them.

Release of Liability:I understand and accept that by declining the heartworm
test, I am assuming the risk that my pet may have an undiagnosed heartworm
infection. I release Advanced Animal Hospital – Wisconsin and its veterinarians and
staff from any liability related to heartworm disease in my pet.

Authorization: I hereby authorize Advanced Animal Hospital – Wisconsin to
dispense heartworm preventative medication to me for my pet without requiring a
negative heartworm test result.

Signature*

Date*

Name

This field is for validation purposes and should be left unchanged.