Heartworm Prevention Request

Heartworm Prevention Request
Do you have a current negative heartworm test for your pet within the last twelve months?*

YesNo
If your pet does not have a current negative heartworm test or prescription, please visit our Vaccine Clinic or contact your care provider to have one performed.
Is your heartworm test on file with the Greenville Humane Society?*

YesNo
If no, please upload a photo of your current heartworm prevention prescription or proof of a negative heartworm test.

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If you have been buying prevention from another vet, please attach proof of previous purchases since last heartworm test with name and contact information of the vet it was purchased through.

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Owner Name

First NameLast Name
Email
example@example.com
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Animal
Animal Weight
What type of heartworm prevention would you like to purchase?
Please indicate what amount of heartworm prevention you would like to purchase:

Single Dose3 Months6 Months1 Year
Additional Comments
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Acceptance of Terms*

I have read and agree to the terms and conditions.
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