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
- Does your pet have a primary veterinarian?
- 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
  
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- What have you tried to raise the funds for your pet's treatment?
  
  Other
- If "Other", please explain:
- Do you have any personal funds to contribute to treatment?
- Owner's available funds to put towards treatment
- Requested Financial Assistance Amount:
- Do you currently receive financial assistance?
- 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)
  
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- I have reviewed the requirements for requesting assistance for emergency veterinary care.
- I have exhausted all other means to raise the funds to treat my pet.
- I attest that the information provided in this application is true to the best of my knowledge.
- I understand that submitting this application does not guarantee I will receive full or partial financial aid.
- Signature
- Please verify that you are human
- Should be Empty:

Application for Financial Assistance

Pet's Information:

Assistance Request: