Pet Crisis Assistance Application
ACT Pet Crisis Support relies on community donations to assist pets whose owners are experiencing financial hardship and may otherwise be forced to consider euthanasia or surrender due to the cost of veterinary treatment. As a condition of applying for assistance, please provide a photo of the pet during their hospital stay that may be shared on our social media channels to help demonstrate the impact of donor support. As our funds are limited, all applications are assessed on a case-by-case basis, taking into account the pet's prognosis, the owner's financial contribution, and the availability of charitable funds. We will endeavour to provide a decision as quickly as possible. Please note that applications can only be submitted by a veterinary clinic who has physically seen and examined the pet.
Application date
-
Day
-
Month
Year
Veterinary clinic details
Please provide the clinic's contact details and the staff member completing this application.
Veterinary clinic name
*
Veterinary clinic phone number
*
Veterinary clinic email address
*
example@example.com
Staff member completing this form
*
Client details
Please provide the client’s details here.
Client name
*
First Name
Last Name
Client contact phone number
*
Please enter a valid mobile number.
Format: 0000 000 000.
Client email address
*
if no email address please put none@none.com
Is the client receiving a Centrelink benefit?
*
Yes
No
Unknown
Has the client exhausted all other financial options?
*
Yes
No
Unknown
Pet details
Please provide the pet’s details here.
Species
*
Dog
Cat
Other
Pet name
*
Age
*
Breed
*
Sex
*
Entire Male
Entire Female
Desexed Male
Desexed Female
Has the owner accessed assistance from the charity before?
*
Yes
No
What pet did they access the charity for
*
What year did they access the charity
*
best gustimate is fine
Pet assessment
Information on the assessment of the pet
How long has the pet been injured or sick?
*
Have you seen and assessed the pet?
*
Yes
No
Is the pet still at the clinic?
*
Yes
No
If the pet is no longer in hospital, please explain why
*
Injury / Condition needing treatment
*
When does the procedure or treatment need to take place?
*
Urgently / Now
Today
Tomorrow / In a few days
Next week or longer
Has treatment for this pet been finalised?
*
Yes
No
Would the pet be euthanised or surrendered if not treated?
*
Yes
No
What is the pet’s prognosis?
*
Excellent
Good with treatment
Guarded
Poor
Additional information
Financial assistance / Costs
What is the maximum total cost of treatment?
*
Invoice amount as per the estimate
How much can the pet owner contribute?
*
Funding gap
How much would you like APCS to fund?
*
Difference
If the difference between the estimate and the owner’s contribution is more than the amount requested, please explain how the remaining balance will be funded.
For example: the clinic will provide an account for the remaining amount.
Please upload an itemised estimate for the procedure or treatment you are requesting funds for.
*
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I agree to provide the final invoice to ACT Pet Crisis Support within 14 days of the procedure or treatment being completed. I understand that estimates are for assessment only and will not be accepted for payment.
*
Yes
No
By ticking this box, I acknowledge and agree that any invoice submitted more than two months after the treatment date will not be covered by ACT Pet Crisis Support. In such cases, payment responsibility will remain with the issuing clinic.
*
Agreed and Understood
As a condition of using ACT Pet Crisis Support funds, we ask that you provide photos of the pet for social media. Please confirm that you have asked the owner for permission to share the pet’s photo.
*
Yes, owner consents to use of photos on social media
No social media for pet
No social media for owner, but photos of the pet may be used on social media
Please upload a photo we can use on social media, or email it to actpetcrisis@gmail.com.
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I understand that the APCS Privacy Policy is available on our website at actpetcrisis.com.
*
Yes
Submit
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