Heartworm Treatment Consent Form

Heartworm treatment carries possible risks and requires strict aftercare for a successful outcome. Such risks and the importance of following post-treatment instructions have been disclosed to me. See below for important information regarding your pet’s treatment:

Resting/Restricted Mobility

• This is a very critical part of the treatment plan for your pet. For a minimum of 30 days after each injection, your pet's activity must be restricted as advised by the veterinarian. Your pet is not allowed to: go on walks (unless going outside to potty only and your pet must be always on a leash), run, jump, or play.
• Failure to restrict your pet's activity as instructed by the veterinarian can result in serious complications including death.
• Common symptoms of complications are, but not limited to, coughing, difficulty breathing, lethargy, vomiting, and not eating and/or drinking (See below for additional information regarding complications).
• Give our office a call during regular business hours if you have any concerns or notice any possible signs of a complication related to treatment. For after-hours concerns regarding possible treatment complications, visit our website www.northwoodah.com and halfway down the middle of our home page you will find a list of several after-hours animal emergency clinics.

Other Possible Complications

• Injection site pain and swelling.
• The primary post-treatment complication is the development of severe pulmonary thromboembolism. Pulmonary thromboembolism is the obstruction of blood flow through arteries of the lungs due to the presence of dead heartworms and injury to the blood vessels from the heartworms.
• When dead worms are numerous and arterial injury is severe, widespread obstruction of arteries can occur. Clinical signs most commonly observed with severe pulmonary thromboembolism include fever, cough, hemoptysis (blood in the sputum), and potentially sudden death.
• If heartworm treatment is effective, some degree of pulmonary thromboembolism will occur. That is why it is extremely important to restrict your pet’s activity during treatment and monitor closely for any sign of complication.

By electronically signing this consent form, you confirm that you have read, understood, and acknowledged all of the information in this form (this form must be completed and on file, at least 3 business days before the start of the treatment).

Please do not submit any Protected Health Information (PHI).