Canine Heartworm Treatment Waiver

Procedure and Risks

Your animal(s) is undergoing Heartworm Treatment. There are inherent risks involved with Heartworm Treatment and other drugs/medications. Injury and/or death can result from the treatment, any related procedures, and from complications following Heartworm Treatment.

LEGACY HUMANE VETERINARY CLINIC does not conduct blood work prior to treatment, and your animal(s) may have unknown disorders of the liver, kidney, blood, and/or other system. Such disorders may increase the risk of complications and/or may be worsened by the use of certain drugs. LEGACY HUMANE VETERINARY CLINIC recommends that blood work be performed at a full service veterinary clinic prior to heartworm treatment. The following conditions increase the possibility of complications and/or death before, during, or after treatment:

1. Animals in advanced stages of heartworms
2. Animals of advanced age
3. Animals suffering from heartworms, intestinal parasites, leukemia, underlying conditions of the organs, or other diseases or injury.

Consent:

I am 18 years of age or older and am the owner (or authorized agent) responsible for the animal(s) described below. I authorize LEGACY HUMANE VETERINARY CLINIC, its staff members, volunteers and/or agents to receive, transport, and perform any and all necessary services for the Heartworm Treatment to be performed upon the animal(s) named below:
Please include name(s), age(s), color(s), and breed(s)

Terms:

I acknowledge that no guarantees or assurances have been made to me regarding the results of the treatment.

I understand the risks involved in my animal’s Heartworm Treatment and that injury to, death of, or post treatment issues may occur. I understand that my animal(s) will be receiving a single injection to treat heartworms on the first day. Thirty days later, I will return for a 2nd injection, followed by a 3rd injection 24 hours later. I assume full responsibility for the consequences that may arise. I understand and accept these risks to my animal.

To my knowledge, this animal(s) is in good health. I verify that, to my knowledge, this animal(s) does not have a previously diagnosed condition. I verify that my animal(s) has not been vomiting, sneezing, coughing, and/or experiencing diarrhea within the past two (2) weeks.

I understand that LEGACY HUMANE VETERINARY CLINIC is not responsible for complications resulting from my failure to follow post treatment instructions, and complications resulting from my failure to keep my animal(s) indoors and contained for 60 days following the first injection. 

I acknowledge that I have received documentation from Adopt My Heart about my pet's heartworm treatment and understand the details about heartworm treatment and assume all risks involved. 

I understand that there are inherent risks in failing to maintain current vaccinations. LEGACY HUMANE VETERINARY CLINIC recommends that animals be vaccinated two (2) weeks prior to treatment. LEGACY HUMANE VETERINARY CLINIC is not responsible for contagious diseases contracted after surgery for which the animal was not previously vaccinated, including, but not limited to, kennel cough. I am responsible for the cost of treatment.

I understand that I MUST pick up this animal(s) on the date and time indicated by LEGACY HUMANE VETERINARY CLINIC personnel. I understand staff is not on site every day or overnight. Failure to pick up my animal(s) will result in your animal(s) being turned over to Collin County Animal Control for abandonment. Charges of abandonment are punishable as a class A Misdemeanor, up to $4,000 in fines and 1 year in jail.  

I understand that there is risk of a moving vehicle accident when my animal is being transported to the clinic and hold LEGACY HUMANE VETERINARY CLINIC and its driver harmless from any liability resulting from any such accident.

To the best of my knowledge, this animal(s) has not bitten any person during the past fifteen (15) days preceding the date of this consent form.

I will provide my animal(s) with a clean, dry, indoor environment for recovery. I will provide post-treatment monitoring and care in accordance with the post-treatment instructions provided to me.

I understand that if my animal dies, the animal will be picked up by me, or the remains will be disposed of in accordance with state laws and the policy of LEGACY HUMANE VETERINARY CLINIC.

I understand that I am responsible for paying all costs of services rendered, including any CPR drugs, the cost of keeping and/or disposing of animals. I understand that the services initialed herein will be included in my final invoice.

I understand if I order any additional services or the veterinarian on duty performs any additional treatments or procedures, I am responsible for payment of such services.

I understand that all services rendered on the day of your treatment will be paid by Adopt My Heart and will be payable via the credit card on file and will be charged prior to patient discharge. 

I understand that it is my responsibility to contact the clinic with alternate card information to be used by 10am on the date of any scheduled appointment.

I hereby acknowledge and agree that should any complications or issues arise between me (or any others with a personal interest in my animal(s), including my spouse, family members, co-owners, etc. ("Other Interested Parties") and LHVC, I will work (and ensure that Other Interested Parties will work) only with LHVC management in person or by telephone to timely and mutual resolution. In such an event, I will not disparage, nor will I allow any Other Interested Parties to disparage, LHVC or any of its officers, directors or employees, in any public forum including social media and internet review websites or applications. For purposes of this section, “disparage” shall mean any negative statement, whether written or oral, about LHVC.

Promotional Materials:

Your signature below allows LHVC to use you and/or your animal's picture in promotional material.

Veterinarian Disclosure

I will not hold LEGACY HUMANE VETERINARY CLINIC, its staff, volunteers, or agents liable or responsible in any manner for any complications that may arise during surgery or as a result of the surgery.

The veterinarian may perform additional treatments or procedures that he/she feels are important to the health of the animal(s). These additional treatments or procedures are beyond the scope of LEGACY HUMANE VETERINARY CLINIC’s services and additional charges may apply.

The veterinarian may also refuse to perform any procedure on any animal for any reason. Such refusal is at the sole discretion of the attending veterinarian. I also understand and acknowledge that LEGACY HUMANE VETERINARY CLINIC may refuse to accept any animal that, in its opinion, could jeopardize the safety of any other animal or person. For any animal declined for medical or safety reasons, you will be charged at least $50 per animal for the exam plus charges for all other services and medications provided.