Prairie Lane Veterinary Hospital - Heartworm Testing Waiver

Heartworm Testing Waiver
2437 S 120th St, Omaha, NE, 68144

(402) 333-3847

clientcare@prairielanevet.com
Today's Date*

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Pet's Name*
Owner's Name*

First NameLast Name
I (Client/Owner Name) blanks* understand that yearly heartworm testing is part of a recommended heartworm prevention program. I have been advised that it is the preferred medical approach to monitoring heartworm disease status and that the test includes testing for three tick diseases: Lyme, Ehrlichia, and Anaplasma. I also understand that failure to test could result in an undiagnosed and, therefore, untreated condition. I have also been informed that my pet must have had an examination within one year before legally obtaining a prescription for a heartworm preventative.
While I understand the above information, I have elected NOT to have testing for Heartworm Disease, Lyme disease, Ehrlichia, or Anaplasma performed on my pet named above.
Owner's Initials Here:*
Further, I release Prairie Lane Veterinary Hospital, its doctors, technicians, and other staff from any liability related to my decision not to have the above-described testing and liability for any adverse reactions associated with using a heartworm preventative drug in any off-label fashion.
Owner's Signature*
Date*

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