Heartworm Waiver — Goose Creek Pet Hospital

I understand that my pet is at risk to contract heartworm disease, especially in high risk areas like Tennessee. I understand that if heartworm disease is contracted by my pet, it could be fatal. I understand that treatment for heartworm disease is not guaranteed and can cost up to $2,000 or more. The American Heartworm Society and manufacturers recommend an annual test for pets receiving the heartworm medication. I will not hold Goose Creek Pet Hospital or its employees liable if my pet contracts heartworm disease or related reactions.

Date

MM

DD

YYYY

Owner Name

First Name

Last Name

Pet Name

I hereby decline:

Heartworm Test

Heartworm Prevention

The Doctor who most recently preformed by Pet's physical exam:

Please type your name to authorize this form.

Plese note- this will act as your signature

Heartworm Test and Prevention Waiver

Goose Creek Pet Hospital