Application/Request for Help

(If you are applying for IVDD treatment, we will only be able to help with conservative treatment at this time. Conservative treatment includes the following: Consultation, Meds, Laser Therapy, and a Wheelchair if needed)

We no longer can pay for regular dentals unless it's an emergency. We are not getting enough funds to be able to support paying for them.

Name*

First NameLast Name

Address:*

Street Address/Unit/Apt. #

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Your Email

example@example.com

Your Phone Number*

Area CodePhone Number

Paypal Email:

example@example.com

I certify that I am the:

Legal Owner of:Good Samaritan of:

Pet's Name:*

Pet's NameAge (if unknown, approximate)

Gender:*

MaleFemale

Please provide a picture of your pet

Browse Files

Briefly describe diagnosis, medical treatment, symptoms or injury, *

Is your pet currently seeking vet care?*

YesNo

Date of Last Vet Visit*

Estimated Cost of Treatment $:

Vet Name:

Vet Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Vet Phone:

Area CodePhone Number

Vet Email

example@example.com

Vet Fax:

Area CodePhone Number

Vet Website:

Did you get an estimate from the vet: seeking care from a vet for this need/condition?*

YesNo

Please Upload a copy of estimate or receipt here

Browse Files

Have you applied for financial aid with any other program/group*

YesNo

Employment Status:*

UnempoyedEmployedRetiredDisabled

Reason or Circumstance:

I certify that all the information provided is accurate and complete. I give consent for the administrators of Dachshund Friends In Deed to review this application & use any of my pictures and description of medical needs for the purpose of promotion and fundraising to get the help my pet needs.

I give permission for the administrators of DFID to talk directly with the provider for my pet to get an accurate accounting of financial needs.

An application for assistance

does not guarantee funding.

If the application is accepted, I agree to join DFID on facebook for the purpose of fundraising for my pet and:

a. to provide help to administrators where needed to promote my application needs for my pet through sharing via social media, with friends, etc.

b. be & remain in contact with DFID at all times with current updates & improvements of my pet.

c. Live in compliance with Dachshund Friends In Deed Community Standards.

d. Continue to support DFID whenever possible to help promote & support other featured pets in need.

Signature

Date

DayMonthYear

Dachshund Friends In Deed is a registered & approved IRS 501(c)(3) non-profit charity. Registered EIN #83-4234530

2717 Commercial Center Blvd, Suite E200 PMB 304 - Katy, Texas - m.me/DFID2019

Email: DFInDeed@gmail.com

Application/Request for Help

Pet Information

Vet Information

Other Circumstances

Conditions Upon Acceptance

Signature