Lilly's Legacy Medical Fund Application Form

Lilly's Legacy Medical Fund

Grant Application 2023-2024
Lilly’s Legacy Medical Fund (LLMF) is Philadoptables new program to provide support and assistance to those with dogs diagnosed with hemangiosarcoma. LLMF provides financial assistance to pet owners in the areas below if their dog is facing an illness related to hemangiosarcoma.

Pennsylvania: Philadelphia, Delaware, Chester, Lancaster, York, Montgomery, Bucks, Berks, Lehigh, Lebanon, Northampton, Carbon, Schuylkill, Luzerne

New Jersey: Camden, Burlington, Ocean, Gloucester, Salem, Cape May, Atlantic, Cumberland, Monmouth, Mercer

Delaware: New Castle, Kent, Sussex

Please contact diana@philadoptables.org with any questions.

If your pet is facing an illness or medical emergency, seek medical attention immediately.
CONTACT INFORMATION
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What county do you live in?*
What is your age?*
What is your preferred contact method?*

EmailPhone CallTextAll of the above
PET Information
Pet Name*
Pet Age*
Pet Type*
Note: At this time, only dogs are eligible for LLMF*
Pet Breed*
Pet Sex*
Is your pet spayed or neutered?*

YesNo
Date of your pet's last veterinary visit?*
Is your pet up-to-date on vaccines?*

YesNo
Do you have pet insurance?*

YesNo
Who is your primary Veterinarian? Please include practice name.*

VeterinarianPractice
How did you meet your pet?*
Please provide in detail, the circumstances with your pet's health/wellness.*
File upload
Please upload a photo of your pet*

Cancelof
Please upload any relevant documents (medical records, diagnosis, invoices, receipts, etc.)

Cancelof
TERMS & CONDITIONS
I acknowledge I am the legal owner of the pet mentioned above and we reside in one of the counties eligible for financial assistance.*

YES
LLMF provides financial support and reimbursement for verified medical expenses associated with the diagnosis, surgery or treatment of hemangiosarcoma. I acknowledge that grant funds may not be used for routine treatment, vaccinations, spay or neuter.*

YES
Decisions from grant submissions may take up to two weeks. I acknowledge that grants are awarded based on availability of funds, individual financial needs, eligibility requirements, and at the sole discretion and abilities of the members of the Philadoptables board.*

YES
I agree that the information given is true, accurate and complete as of the date of this application submission.*

YES
Should be Empty:

Lilly's Legacy Medical Fund

CONTACT INFORMATION

PET Information

File upload

TERMS & CONDITIONS