Short Term Care - Dog Information Form

Phone

This 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 available

Emergency Contact Phone*

Dog's Vet's Name*

Dog's Vet's Phone*

Dog 1

Dog's Name	Age	Breed	Weight	Sex	Spayed/Neutered?	Date of Birth

Dog 2

Dog's Name	Age	Breed	Weight	Sex	Spayed/Neutered?	Date of Birth

Dog 3

Dog's Name	Age	Breed	Weight	Sex	Spayed/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

Current photo of your dog*

Accepted file types: jpg, png, gif, Max. file size: 1 GB.

(jpg,png,gif only)

Your Contribution helps support HWAH.

Our suggested value is $45.00 for the first dog and $25.00 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.

Short Term Care – Dog Information Form

Dog Information Form

Your Contribution helps support HWAH.

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