The Wolf Project
An Access to Care Initiative under SGT Canines
Financial Care Assistance Application
Please complete this form as thoroughly as possible. Submission does not guarantee funding. Cases are reviewed based on medical urgency, prognosis, and available funding. We do not reimburse already covered treatments. We provide access to care in emergency situations when treatment is available and prognosis is good.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Dog Information
Dog's Name
*
Dog's Breed
*
Dog's Age
*
Dog's Sex
*
Current Status:
*
Please Select
At home
At vet
hospitalized
Veterinary Information (Rescue Partnered Vets: LeadER, VEG, Arch Creek Animal Clinic, Hearts for Paws, Town & Country)
* Vet records + estimates must be submitted to us
Veterinary Clinic/ Hospital Name
*
Clinic Phone Number
*
Clinic Email
*
Date of hospitalization or most recent exam
*
Medical Situation
Please submit the complete diagnostic report, clinical summary, or treatment plan along with all estimates and invoices. Without the included files uploaded, approval will not be allowed./
What is the diagnosis?
*
What treatment is recommended?
*
Is this a medical emergency? (Treatment must begin ASAP)
*
Yes
No
What is expected outcome if treated? Ex: Prognosis - poor, guarded, good, excellent
Please upload the treatment plan
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please upload the invoice estimate along with required deposit
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Cost + Need
Total estimate for treatment
*
Amount needed right now
*
How much can you contribute? (give number amount)
*
Please select options you have already tried:
*
Care Credit
Pet Insurance
Financial Assistance through the vet practice
Other
If you applied for care credit or any other financial assistance program, please confirm you were declined.
*
Do you have pet insurance? (Yes or no) If yes, what is their reimbursement plan?
*
Agreement
Applications are reviewed based on urgency, prognosis, and available funds. If approved you will be contacted directly using the number given above. By submitting this form, you grant us permission to contact the vet and will grant the vet full permission to share all medical treatment plans, updates, estimates, and evaluations with us. By submitting this form, you agree to stay in contact with us throughout the medical journey and recovery. You agree to provide us with explicit photo content at the vet, during recovery, and post recovery. You agree to allow us to use your photos publicly as proof of impact and to share your dog's story.
Checkboxes:
*
I understand by submitting this application, it does not guarantee funding
I understand approved funds are payed directly to the veterinary provider.
I confirm all information is up to date and accurate.
I confirm that I own the dog and it is registered to me.
I understand that content is a crucial part to fundraising and will provide all content requested.
I understand that partial funding may be granted.
I understand that this request is only to treat the current medical condition based off uploaded diagnostics.
If approved, I will send The Wolf Project the amount that I am able to provide.
If approved, any fundraising by the owner will be sent to support The Wolf Project or reimburse for the case.
I understand that any money raised for my dog is only to cover treatment costs. No additional funds for their case will be used for my personal expenses.
Signature
Date
-
Month
-
Day
Year
Date
Continue
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Should be Empty: