Application for Financial Assistance

Application for Financial Assistance

Please complete each section below...
- Owner's Information:
- Full Name*
  
  First NameLast Name
- Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Phone Number*
  Format: (000) 000-0000.
- E-mail*
- Owner's Birth Date*
  
  MonthDayYear
  Date
- Pet's Information:
- Pet's Name*
- Species*
- Breed*
- Pet's DOB or Age*
- YesNo
- If "Yes," please tell us your pet's primary veterinary Clinic.
- Does your pet have any pre-existing medical conditions?
- Assistance Request:
- Treating Veterinary Clinic*
- Clinic Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Clinic Phone Number*
  Please enter a valid phone number.Format: (000) 000-0000.
- Clinic Email Address:*
  example@example.com
- Diagnosis*
- Treatment Plan Estimate*
- Please Upload the Treatment Plan & Estimate from your Veterinary Clinic*
  
  Cancelof
- Applied for Care CreditApplied for Scratch PayAsked Friends & FamilyOther
- If "Other", please explain:
- YesNO
- Owner's available funds to put towards treatment*
- Requested Financial Assistance Amount:*
- No, I do not receive assistanceFederal Assistance (SSI,SSDI,SSA Benefits)MedicaidDisabilityState of NH Assistance (TANF, WIC, SNAP, Housing Assistance)State of NH UnemploymentOther reason for requesting assistance (please explain below)
- If "Other Reason" above, please let us know why you are requesting assistance:
- If you have documents relate to your above reason for requesting assistance, please upload here. (If you do not have documented proof, we may still reach out asking you to show proof)
  
  Cancelof
- Yes
- Yes
- Yes
- Yes
- Signature*
- Please verify that you are human*
- Should be Empty:

Application for Financial Assistance

Pet's Information:

Assistance Request: