Hugo Foundation Assistance Form

Application for Assistance from The Hugo Foundation
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Pet's Name
Pet Species
Breed
Color/Description
Approximate Age

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Pet's Gender
Spayed/Neutered?
Have you ever applied for Care Credit?
If yes, please indicate date applied:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Were you approved or denied?
If denied, please submit the denial declaration page below:

Cancelof
Hugo grant amount requested:
Veterinarian:

First NameLast Name
Veterinarian Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Veterinarian Telephone
Please enter a valid phone number.Format: (000) 000-0000.
Diagnosis:
Prognosis:
I attest that all information I have provided in this form is accurate and complete. I give consent for all the above mentioned care at the treating doctors' discretion. I fully understand that donation of this grant in no way causes The Hugo Foundation to assume any liability for my pet and does not ensure outcome of any treatment provided. I understand that any photographs or documentation may be used for purposes of promotion and fundraising.

Please submit any supporting documents or photos to contact@thehugofoundation.org.
Signature
Should be Empty:

Application for Assistance from The Hugo Foundation