Consent Form For Refill Of Heartworm Medication

CONSENT FORM FOR REFILL OF HEARTWORM MEDICATION WITHOUT A BLOOD TEST OR PROOF OF CONTINUAL USAGE

I, 

 or designated representative, do hereby certify that I am the owner of

. It has been explained to me that both the AVMA and the heartworm preventative drug manufacturers recommend testing for heartworms every year even if on constant monthly preventative prior to prescribing heartworm medication. 

• I understand that it is possible for  to get heartworms even if on monthly preventative. This can be caused by missing a dose, vomiting up medication unbeknownst to owner, inappropriate dosing or rarely, product failure.
• I understand that giving heartworm preventative to a dog that is positive for heartworms may cause serious illness up to and including death.

• I understand that by not annually testing for heartworms or by purchasing heartworm prevention from the internet, I will void any manufacturer’s compensation offered for treatment of heartworm disease.

I hereby waive the testing process and release the doctors and staff of East Maiden Animal Clinic from any and all liability for any reactions from giving heartworm medication to my dog without prior testing. Any medications other than approved methods are considered “off-label” and have not been evaluated for efficacy and as such Hidden Valley Animal Clinic resumes no responsibility for any adverse side-effects they may cause.