Form
DOXIE FOUNDATION VETERINARY ASSISTANCE APPLICATION
SECTION 1: APPLICANT INFORMATION
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Preferred Method of Contact: Email, Phone or Text Message
*
SECTION 2: DACHSHUND INFORMATION
Dachshund's Name
*
Age
*
Gender:
*
Male
Female
Spayed/Neutered
*
Yes
No
Color
*
Please Select
Red
Black and Tan
Cream
Coat
*
Please Select
long hair
smooth
wire
Weight
*
How long have you owned your dachshund?
*
Upload a Current Photo of Your Dachshund
*
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of
SECTION 3: MEDICAL INFORMATION
Medical Condition or Diagnosis
*
Date Symptoms Began
*
-
Month
-
Day
Year
Date
Emergency Situation?
*
Yes
No
Has Your Dachshund Been Examined by a Veterinarian?
*
Yes
No
Detailed Description of Medical Need
*
SECTION 4: TREATING VETERINARIAN
Veterinary Clinic Name
*
Veterinarian Name
*
Clinic Address
*
Clinic Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Clinic Email Address
*
example@example.com
May Doxie Foundation Contact Your Veterinarian?
*
Yes
No
SECTION 5: FINANCIAL ASSISTANCE REQUEST
Estimated Cost of Treatment ($)
*
Amount Requested From Doxie Foundation ($)
*
Amount You Can Contribute ($)
*
Have You Applied To Other Assistance Programs?
*
Yes
No
If Yes, Explain
*
SECTION 6: HOUSEHOLD INFORMATION
Number of Adults in Household
*
Number of Children in Household
*
Annual Household Income Range
*
under $25,000
$25,000–$50,000
$50,000–$75,000
$75,000–$100,000
Over $100,000
Describe Your Financial Hardship
*
SECTION 7: DOCUMENT UPLOADS
Veterinary Estimate or Invoice
*
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Medical Records
*
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Treatment Plan
*
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Additional Supporting Documents
*
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SECTION 8: CERTIFICATION
I certify that the information provided is true and accurate.
*
I certify
Electronic Signature
*
Date
*
-
Month
-
Day
Year
Date
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