First Name*

Last Name*

Address

City

State/Province

Zip/Postal Code
 - 

Email*

Home Phone

Work Phone
x

Cell Phone

Alt Email

Name of animal you are adopting*
Choose an animal: Akira Anna Aquilla Archer Belle Brock Celeste Daphne Emmie Faith George Hannah Helena Henry Hercules Hilary Howie Humphry Indiana Indigo Ivan Izzy James Jen Jett Kandy Kewpie Kim Kitty- SB Ladie Ladybug Lainey Laredo Lubbock Lufkin Maddox-SB Madison Maeve-SB Maisie- SB Maria Meena- SB Miss Priss- SB Molly Mora Morgan- SB Peter Pinto Bean- SB Radish Sam Shelly Sir Kingsley Tator Terrie Trudy Winkie Zeus

If your dog was not listed in the drop down box, please fill in the name of dog you are adopting:*

Please list your veterinarian's Name, Address and phone number below*

Veterinarian's Phone Number*

I have been told that my adopted dog has tested HW+ and I have had the “Slow-Kill Treatment Protocol” explained to me, along with the name & contact information for the Great Pyrenees Rescue Society’s Heartworm Positive medical coordinator.

I agree to follow the treatment guidelines of the “slow-kill treatment protocol” and have discussed this with my vet, who will support me in this treatment plan.

I agree to stay in contact with the rescue, and specifically with the HW+ coordinator, to request more medications as needed (which the rescue will provide) and to give status updates on my dog’s HW treatment plan.

I understand that the “Slow-Kill Treatment Protocol” can take up to 18 months to show a “negative” heartworm status for my dog. Depending on the severity of the heartworm infection, some may be sooner and some may be later – but that most heartworm positive dogs do test negative within 10 months to 14 months.

I understand that due to the physiological differences of the Great Pyrenees breed, to have a slower metabolism and higher negative physical reactions to the medications in the “fast kill” treatments, that the Great Pyrenees Rescue Society requires that all HW+ dogs adopted through this rescue must use the “slow-kill treatment” for their health and well-being.

I understand that if I decide to break this contract, and begin the fast-kill treatment plan on my adopted dog, that I am responsible for all medical issues and/or side effects that may arise from using the fast-kill medications.

I understand that if my adopted dog develops seizure disorders, neurological disorders, or dies from the fast-kill treatment plan, that I will not be reimbursed for my dog, and I will not be given a “replacement dog”, and I will not be allowed to adopt from the Great Pyrenees Rescue Society again.

Signature:*