Keyboard Accessible Menu
Skip to content
Arrival Check-in
(773) 478-0631
CHESHIRE PARTNERS + VHMA
Digital Client Center
Client Arrival Check-In
Client Survey
Drop Off Questionnaire for Sick Pet
Heartworm Treatment Release Form
New Patient Form
Pay Online
Prescription Refill
Well Pet Drop Off Form
Surgery / Dental Drop Off Form
Event Booking System
Lectures
My Bookings
Locations
Team Portal
Documents & Forms
Staff Directory
Announcements
E-commerce
Portfolio
Contact
Menu
Digital Client Center
Client Arrival Check-In
Client Survey
Drop Off Questionnaire for Sick Pet
Heartworm Treatment Release Form
New Patient Form
Pay Online
Prescription Refill
Well Pet Drop Off Form
Surgery / Dental Drop Off Form
Event Booking System
Lectures
My Bookings
Locations
Team Portal
Documents & Forms
Staff Directory
Announcements
E-commerce
Portfolio
Contact
Heartworm Treatment Release Form
All required fields are marked {*}
Client Information
Client Name:
First
Last
Today's Date:
Month
Day
Year
Client Email:
Patient Name:
Color:
Sex:
Male
Female
Spayed/Neutered?
Yes
No
Age:
Breed:
I authorize the performance of the following procedure(s):
Is your pet currently on a special diet (including treats)?
Yes
No
If "Yes" above please explain:
Has your pet had any medications in the last 24 hours (including non-prescription medication or supplements)?
Yes
No
If "Yes" above please explain:
Included in the heartworm treatment package is: A complete physical exam, pre-treatment bloodwork, radiographs, immiticide injections (Based on the weight of the animal), steroid injection(s), and three days of boarding.
Do you need a refill on heartworm, flea, and tick prevention?
Yes
No
If "Yes" above which preventative do you need and how much would you like?
Please list any vaccinations your pet is currently due for: (If they are up to date please say None)
I Authorize
Do we have your authorization to bring them up to date on their shots?
• Did your pet having any coughing which required a steroid to treat?
Yes
No
If "Yes" above please explain
If your pet has received the first melarsomine injection, did they have any back pain that required medication?
Yes
No
I Understand and Accept
I understand that while the treatment used in this hospital is one of the safest used in veterinary medicine, NO treatment is without medical risks. No guarantee can be made legally or ethically to me on the outcome of any procedure performed. Any complications arising from the above procedure will charge for at time of recheck visit.
Name
First
Last
Signature
Phone number where you can be reached TODAY (Very Important)
CAPTCHA
Phone
This field is for validation purposes and should be left unchanged.
