Short Term Care – Dog Information Form Dog Information Form X/TwitterThis field is for validation purposes and should be left unchanged.Email* How did you hear about us?*Name* First Last Address* Street Address City State / Province / Region ZIP / Postal Code Phone*Emergency Contact Name* First Last * If you are not availableEmergency Contact Phone*Dog's Vet's Name*Dog's Vet's Phone*Dog 1Dog's NameAgeBreedWeightSexSpayed/Neutered?Date of Birth Dog 2Dog's NameAgeBreedWeightSexSpayed/Neutered?Date of Birth Dog 3Dog's NameAgeBreedWeightSexSpayed/Neutered?Date of Birth Feeding Instructions (Be specific for each dog)*Medications: Names, Dosages, Administration Requirements (Be specific for each dog)Health Issues, limitations, diseases.(Be specific for each dog)Special Needs (Check all that apply) Cannot do stairs Advanced age Needs special medications Separation anxiety Special feeding needs Needs help walking Incontinent End of Life Other When your dog goes outside (Check all that apply) Can run and play in the large fenced yard Must stay in small stone/patio area Must be leash walked Can play with other friendly dogs (we cannot assume liability if dogs are hurt while playing) Must go out alone Photo Drop files here or Select files Accepted file types: jpg, gif, png, pdf, Max. file size: 1 GB. Your Contribution helps support HWAH.Our suggested value is $50.00 for the first dog and $30.00 for each additional dog (this is the Local Fair Market value). Any donation in excess of that amount is allowable under IRS guidelines for Charitable Contributions.I agree to reimburse Sher Polvinale/HWAH for any expenses incurred.(initial below.)Intial aboveI understand that HWAH is not responsible for unexpected circumstances beyond their control which may cause a change in their ability to provide short-term stay care for my dog.Intial aboveI understand that dogs can be unpredictable and if I want my pet to interact with other dogs while at HWAH there is a possibility that my dog could be injured.Intial aboveI understand that the HWAH yards are fenced with great care and maintained, however if my pet is allowed to run in the fenced yards and jumps the fence, this is beyond the control of Sher Polvinale/HWAH.Intial above Δ
