Sheila's Legacy - HW+ Treatment
Please review each section in regards to heart worm treatment for your pet.
Email address *
Name of Contact person *
Phone number *
Name of Rescue group *
Name of pet *
Breed of pet *
Weight of pet *
Has your Dog already completed 30 Days of Doxycycline *
If the answer is yes to the above question what was the date of the last dose of Doxycycline *
Are you able to get a 30 day supply of Doxycycline from your Veterinarian? *
Were you referred by Funding4Fido. If yes, please provide the approval code. *
Do you require Boarding for the duration of the treatment only. Please understand this will be a separate fee that will need to be paid directly to the veterinarian. *
Do you understand that you must check in with New Life Representatives, and payment of $100 ( For just the Injection is due prior to treatment) *
Do you understand that payment is due at the completion of this form to WITH A NOTE OF THE ANIMALS NAME or name will not be placed on the schedule. This is non-refundable *
At the completion of this form ALL medical records must be emailed prior to the appointment. They must be emailed to *
If you do not attend at the time provided you will not be eligible for future appointments, and you will not be eligible for the discounted rates provided. Do you understand? *
Do you understand that attempting to utilize this opportunity without the knowledge of NLIFSR directly jeopardizes the ability to continue to build supports and help other rescues. If this is to take place you will not longer be eligible to complete any program with NLIFSR *
Please write your Full name Phone number name of rescue and title. By completing this you are confirming you have read all the above statements and understand without a doubt the expectations of this program and any waivers or exceptions will not be tolerated and will result in the immediate terminations of benefits. *
I understand that all correspondence will be sent via email and you will be required to make and keep all appointment times. *
Please Upload Vet Records or email them to
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