Diagnostic Testing Decline Form

Name *

First

Last

Email *

Pet's Name *

I the undersigned owner of the pet named above have been informed that my pet is in need of additional diagnostic testing in the form of bloodwork which include but are not limited to a complete blood count, blood chemistries, urinalysis and thyroid check. I decline the appropriate procedures described to me by the staff/veterinarians at Animal Hospital of Lake Villa. *

I fully understand that some sick or emergency situations require bloodwork as it provides the appropriate information for the veterinary staff to make immediate decisions so that they an help your pet as soon as possible.
I understand that preventative care screenings are essential because the signs of sickness are not always obvious and as such, preventative care screenings can help uncover disease before it is too late. I am fully aware that the American Veterinary Medical Association and the American Animal Hospital Association both recommend preventative blood screening every 6 months on patients over 7 years old.
I have been made aware that some medications may have side effects that could cause my pet harm and for that reason, if my pet has been on these medications, blood work screening will be required every 6 months. This will allow the veterinary staff to make necessary changes or medication adjustments in order to help my pet remain healthy. I have been made aware that failure to have this bloodwork done periodically may harm my pet and as such may result in a declined approval from my veterinarian to continue these medications.
That many groomers and boarding facilities will require specific vaccinations and that as such, should I choose to get my pet groomed or boarded may need to come back to get these vaccinations done. I am fully aware that should my pet lose his valid doctor patient relationship or require a rabies vaccine, there may be an additional exam fee should I return for these vaccinations.
I have been informed that the rabies vaccination is required by law and failure to update this vaccine may result in fines from local Animal Control facilities.

Please make sure that all boxes are checked before continuing.

I have been informed of the complications that might arise but I still choose to decline bloodwork and chemistries. By doing so, I make myself fully responsible in the event that my pet become ill or results in death from failure to adhere to this hospital's policy and the well known recommendations from the veterinary staff. The complications have been explained to me by the staff/veterinarians. *

I choose to decline testing at this time.

Signature *

Today's Date *

Animal Hospital of Lake Villa
101 S. Milwaukee Ave.
Lake Villa, IL 60046

Phone: (847) 356-8387
Text: (847) 356-8387
Fax: (847) 356-2817

Premier Veterinary Group
Emergency: (847) 548-5300