Heartworm Test Results

Instructions

Complete the following to provide the results of the heartworm test.

Contact Information
Enter your first name
Enter your Last Name
Use format: user@domain.com

Dog Information
Enter the heartworm positive dog's name when you adopted them from HADR. If you don't know, enter their current name.
Enter the current weight of the dog.

Heartworm Test Information
Enter the date of the heartworm test.
Select the provider that performed the heartworm test.
Enter vet's office name performing the heartworm test.
Enter the phone number of the vet's office that performed the heartworm test.
Select the status of the most recent heartworm test.
Attach a copy of the heartworm test results from the veterinarian who performed the test.

Signature

By submitting this request, I certify that the above information is true and correct under the penalties of perjury.

If you are using a phone or tablet to complete this application, simply sign your name below. If you are using a computer, use your mouse to write your name below.
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Select today's date

Click submit once. It may take up to 30 seconds for the screen to change. Do not click submit more than once.