PET ASSISTANCE FINANCIAL REQUEST
This form is to be used for a single animal. If you have more than one financial request, you must submit this form for EACH animal.
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Pet Information
Pet Name
Species (dog, cat, other- specify_
Age (months, years and months)
Sex
Male
Male-neutered
Female
Female, spayed
Up to Date of vaccinations:
yes
No
scheduled
Pet Health Status:
Healthy (other than condition for which assistance is needed)
Internal Parasites (hookworms, tapeworms, roundworms, etc.)
Heartworm disease
Ticks
Fleas
Mange or other skin condition
Pregnant/in heat
Feline Leukemia or other feline immune system condition
Other please explain in notes below
Notes:
Please provide the name of your veterinarian:
Status
Personal pet
Stray taking care of
Other
Explain if other
Type of assistance needed
Do you represent any of the categories below (check all that apply):
Currently a participant in government financial assistance programs
Retired
Unemployed
Homeless
Senior
Cost of treatment/procedure beyond our current means
Unable to qualify for credit options
Other (explain within your story below)
Your story
Do you currently have some funding to go toward the treatment/procedure:
yes
no
working on it
If response to above is yes or working on it please explain:
We make every effort to assist as many animals as possible; however, we are an all donation funded group and funds are often very limited. Your submission of this request does not guarantee we will cover the expense of your veterinary assistance. You will be notified within one week if we will cover any portion of this expense. At this time, we limit coverage of expenses to residents in and around the CSRA. By submitting this request, you are consenting to periodic emails from our group, which may be solicitous in nature.
Date
-
Month
-
Day
Year
Date
Signature
Clear
Type a question
Type option 1
Type option 2
Type option 3
Type option 4
Submit
Should be Empty: