Heartworm 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 due for a heartworm test and/or heartworm preventions. In addition, I am fully aware and understand the following by checking them off. *

I understand that my dog/cat is at risk to contract · hearworm disease.
I understand that if hearworm disease is contracted, it could be fatal.
I understand that the heartworm treatment for hearworm disease is not guaranteed, can be harmful to the body as a whole and can cost up to $1,500 or more.
I understand that while some heartworm prevention products like but not limited to, Heartgard, Sentinel and Proheart guarantee their products, failing to perform a heartworm test will make that guarantee invalid since there is no way of proving that my pet did not already have heartworms prior to the preventions.
I understand that my veterinarians recommendation is to keep my pet on heartworm prevention year round and test for heartworms annually.

Please make sure that all boxes are checked before continuing.

I Hereby Decline the Following *

Heartworm Testing
Heartworm Preventatives
Both

Signature *

By signing this form, I understand the complications of declining heartworm testing as provided to me by the staff members at Animal Hospital of Lake Villa and still choose to decline to test. I am aware of the complications of using monthly or yearly heartworm prevention without an annual check for heartworms. I hold both veterinarians and staff harmless should illness, injury or death result from declining the recommended care.

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