Drug Waiver (Heartworm Prevention)

First/Last Name*
Date*
Date Format: MM slash DD slash YYYY
Pet's Name*
Prescribed Medication*
This may be Milbegaurd, Proheart, Heartgaurd, Triheart, etc.
We recommend yearly heartworm/lyme/ehrlicia/anaplasma blood testing for all pets even if they are on year round prevention. Potential complications of giving heartworm prevention without prior testing include respiratory distress and death.*
- I understand the above statement
By signing this form you understand that your pet is being treated with a medication that has the potential for serious side effects. You understand that Sequist Animal Hospital recommends regular blood monitoring for pets that are on the medication indicated above. You are aware of the potential complications of your pet's medication and have elected not to follow the recommended blood monitoring schedule. You agree to release Sequist Animal Hospital of all claims arising from not following their recommendation concerning drug monitoring.*
- I understand the above statement
Initial Here*
By typing your initials in this box you agree to all of the above and fully understand the potential complications.