Heartworm Test and Preventative Waiver Date MM DD YYYY Owner Name * First Name Last Name Pet Name * 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. My veterinarian's recommendation is routine heartworm tests and prevention. I Hereby Decline: * Check all that apply Heartworm Test Heartworm Prevention Primary Veterinarian: Please select the veterinarian that last saw your pet. Dr. Dobson Dr. Randolph Dr. Zuber Thank you!