Application for Financial Assistance
Please complete each section below...
Owner's Information
Owner's Information:
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone Number
*
E-mail
*
Owner's Birth Date
*
-
Month
-
Day
Year
Date
Pet's Information
Pet's Information:
Pet's Name
*
Species
*
Please Select
Cat
Dog
Breed
*
Pet's DOB or Age
*
Does your pet have a primary veterinarian?
*
Yes
No
If "Yes," please tell us your pet's primary veterinary Clinic.
Does your pet have any pre-existing medical conditions?
Financial Aid Request
Assistance Request:
Treating Veterinary Clinic
*
Clinic Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Clinic Phone Number
*
Please enter a valid phone number.
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?
*
Applied for Care Credit
Applied for Scratch Pay
Asked Friends & Family
Other
If "Other", please explain:
Do you have any personal funds to contribute to treatment?
*
Yes
NO
Owner's available funds to put towards treatment
*
Requested Financial Assistance Amount:
*
Do you currently receive financial assistance?
*
No, I do not receive assistance
Federal Assistance (SSI,SSDI,SSA Benefits)
Medicaid
Disability
State of NH Assistance (TANF, WIC, SNAP, Housing Assistance)
State of NH Unemployment
Other 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)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
I have reviewed the requirements for requesting assistance for emergency veterinary care.
*
Yes
I have exhausted all other means to raise the funds to treat my pet.
*
Yes
I attest that the information provided in this application is true to the best of my knowledge.
*
Yes
I understand that submitting this application does not guarantee I will receive full or partial financial aid.
*
Yes
Signature
*
Please verify that you are human
*
Continue
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