Handicapped Pets Foundation Wheelchair Application

Pet Wheelchair Application
*This application form is for wheelchair requests only.*

There are three parts to this application:
- Your contact info;
- Your pet's background and medical info; and
- Pet photos and financial hardship documentation.
Incomplete applications will not be considered.
Your Information
Name*

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pet's Information
Name*
Pet's Name
Species*

DogCatOther
Breed*
Age*
Weight*
Describe your pet's overall health.*
Cause of mobility loss*
Describe your pet's condition & how long your pet has been disabled.*
What is the vet's diagnosis & recommendation?*
What type of mobility device are you requesting?

*Additional information on the different types of wheelchairs can be found at https://www.walkinpets.com/collections/adjustable-dog-wheelchairs/.
*
prevnext( X )
Rear Support Wheelchair
$ Free Size



Quad-Wheel Full Support Wheelchair
$ Free Size



Other
$ Free
If "Other" selected above, please specify requests below.
Any additional information you would like us to consider as we review your application?
Photos & Documentation
Please submit a current photo of your pet.*

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Please provide a document with your name & address demonstrating that you receive governmental aid or assistance. *

Documentation may include proof of disability, welfare benefits, food assistance, housing assistance, TANF, SSI, unemployment, etc.
Cancelof
By signing the below, I confirm that the information provided in this application form is true to the best of my knowledge. *

Clear
Please verify that you are human*
Should be Empty:

Pet Wheelchair Application

Your Information

Pet's Information

Photos & Documentation