Medical Funds Assistance Application

Finley Fort Foundation Emergency Funds Application

Application for Veterinary Medical Financial Assistance
Contact Information
Recipient's Name*

First Name (Person)Last Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Pet's Name*
Instagram Handle
Photo Upload*

To be used for Finley Fort Foundation marketing purposes
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Veterinary Hospital or Clinic Name *
Estimate or Invoice Amount of Treatment*
Upload Medical Estimate or Invoice*

Cancelof
{petsName} 's Story*
Medical issues, Story, Reason for Assistance, Additional Info (Age, breed, etc.). Used for marketing updates.
Do you have Pet Insurance*

NoYes
If you have Pet Insurance, what is the estimated expected reimbursement?
Estimated $ or % to be refunded by Insurance
Did you apply for any other assistance (ex: CareCredit)*

CareCreidtOther
Current Employment?*

Full TimePart TimeOther
Gross Annual Household Income (estimated before taxes)*

Less than $25,000$25,000 to $49,000$50,000 to $74,999$75,000 to $99,999$100,000 to $149,999$150,000 to $199,999$200,000 or more
How will you (how did you) pay for the procedure(s). Check all that apply*

Cash/Check - out of pockedCare CreditCare CreditInsurance ReimbursementOther
How did you hear about Finley Fort Foundation?*

Vet/Clinic ReferralFriends or FamilyWebsite/Online SearchNewsMagazineOther
Terms & Conditions:

Finley Fort Foundation (FFF) can not guarantee full medical cost reimbursement. Not all applications will be approved. If approved, FFF will pledge the awarded amount and pay the hospital or clinic directly at the time of treatment via mailed check or secure online payment methods. Please verify with your clinic if this is acceptable.

The recipient agrees to provide any documentation needed for FFF accounting or tax purposes. The medical provider must accept payments over the phone and be able to supply a receipt or invoice directly to FFF. If an insurance reimbursement exceeds the amount provided, the recipient will return the difference to FFF.

All recipients of any FFF funds will provide photos, videos, or updates upon request that may be used on, but not limited to, FFF social media accounts, finleyfortfoundation.org, or other marketing materials.

We kindly ask for your support in raising awareness of FFF's mission and promoting fundraising efforts so FFF can help more of Hawaii's pets receive the care they need.
I, {recipientsName}, agree to the Terms & Conditions of Finley Fort Foundation*

Clear
Recipient
Should be Empty:

Finley Fort Foundation Emergency Funds Application

Contact Information