Heartworm Treatment Informed Consent Form
Nature of Condition
My dog has been diagnosed with heartworm disease (Dirofilaria immitis).
Heartworms are parasitic roundworms that live in the heart, lungs, and
associated blood vessels. Untreated heartworm disease is fatal.
Proposed Treatment
The recommended treatment involves a series of three deep intramuscular injections
of melarsomine dihydrochloride over a 30-day period, following a 60-day
stabilization phase that includes doxycycline and heartworm prevention administration.
Risks and Complications — I Have Been Informed of the Following
- Injection site pain, swelling, or abscess
- Pulmonary thromboembolism (PTE) — potentially fatal blockage of lung blood
vessels by fragments of dead worms
- Respiratory distress or failure
- Adverse drug reaction
- Rare risk of death, even with appropriate treatment
- Treatment may not eliminate 100% of worms — a 9‑month antigen retest is
required to confirm success
I Understand and Authorize
- Melarsomine dihydrochloride injections per the AHS protocol
- Supportive medications including prednisone and analgesics
- Hospitalization on injection days for monitoring as needed
- Emergency treatment if a reaction occurs
- I have been counseled on the exercise restriction requirements and agree to comply.
- The estimated cost of treatment has been reviewed with me.
Exercise Restriction & Cage‑Rest Agreement
I, the undersigned owner/guardian of the above patient, have been informed of
and understand the following:
My dog has received or is receiving treatment for heartworm disease using
melarsomine dihydrochloride (Immiticide/Diroban). During treatment, adult
heartworms die and their bodies are resorbed through the lungs. Physical
activity significantly increases blood flow and the risk that fragments of
dead worms will block pulmonary blood vessels (pulmonary thromboembolism).
Pulmonary thromboembolism (PTE) is potentially life‑threatening and can result
in respiratory failure or death. The risk of PTE is greatest in the 4–6 weeks
following each melarsomine injection.
I Agree to the Following Restrictions for a Minimum of 6–8 Weeks:
- Leash walks only — for bathroom purposes only, no extended walks
- No running, playing, or chasing
- No jumping on or off furniture
- No off‑leash activity of any kind
- No dog parks, doggie daycare, or interactions with other active dogs
- Confinement to a crate or small room when unsupervised
- Keeping the dog calm and avoiding stimulating situations
I understand that failure to follow these restrictions significantly increases
the risk of serious complications and may result in the death of my pet and
that WWVC is not responsible for complications that arise as a result of
non‑compliance with these restrictions.
