Piper’s Pals Agreement Piper's Pals Agreement LinkedInThis field is for validation purposes and should be left unchanged.How did you hear about us?*Name* First Last Address* Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email* Phone*Dog's Name*Dog's Date of BirthMonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender* Male Female Spray/Neutered* Yes No *Dog BreedDog WeightDog Color Description and Personality*Photo of Dog*Accepted file types: jpg, gif, png, Max. file size: 1 GB. Feeding Instructions*Medications: Names, Dosages, Administration RequirementsHealth Issues, limitations, diseases.Check all that apply Cannot do stairs Advanced age Needs special medications Separation anxiety Special feeding needs Needs help walking Can play with other friendly dogs Incontinent Must go out alone End of Life Other I agree to set up an account at the current HWAH Vet (Kentlands Vet) to be billed directly for any medical needs and prescriptions.*InitialI agree to set up an account at the current HWAH Emergency Vet (VRA) to be billed directly for any medical emergencies.*InitialI 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.*InitialI 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.*Initial aboveADVANCED DIRECTIVEShould emergency medical attention be necessary, every attempt will be made to notify the Owner regarding such situation. If the Owner is unavailable, the Owner authorizes Sher Polvinale/HWAH to approve medical and/or emergency treatment (excluding euthanasia) as recommended by a veterinarian. The Owner releases Sher Polivnale/HWAH from all liabilities related to treatment and expense.*Initial aboveIn the case of a medical emergency, do you want your pet to be held at the Vet on life support until you are notified?* Yes No Do you want your pet to be euthanized if he/she is suffering* Yes No In the event of your pet's death, do you want a pawprint done if available?* Yes No In the event of your pet's death, do you want he/she to be cremated and ashes returned?* Yes No I have reviewed this agreement in its entirety. I have made the appropriate choices. The information provided by me is complete and accurate and I agree to all its terms and conditions as set out above. Please put your name and date below.* First Last Date* MM slash DD slash YYYY Δ
