ASK FOR HELP

This form's instructions are best viewed on a computer rather than a Tablet or Phone. The instructions for each field are situated in the left column. On smaller devices, the left column doesn't line up with the associate questions or it displays above all fields which can cause confusion.

Please complete all fields in sections marked with *.

*Your Contact Details:

*Please select the needed response timeframe:

*Please select one statement that best describes the current medical situation for your pet:

*Please tell us the total cost estimated by your Vet Clinic:

*Please tell us the amount you can comfortably pay at the time of services (we require you to pay something):

Please tell us the total amount of committed donations from other resources (do not include in the amount you can pay above):

Please tell us the amount your Insurance will pay / reimburse (do not include in the amount you can pay above):

*Financial Information:

In the next 3 fields, enter whole numbers only...

Enter your current year expected ANNUAL gross income:

Enter the ANNUAL gross income reported on last year's Tax Return:

Enter the ANNUAL gross income reported on your Tax Return 2 years prior:

The questions about Payment Plans are optional. Please answer them only if you are comfortable repaying the amount needed

(your answers do not impact our ability to assist):

*Financial Status (select ONE):

(if you receive SSI or SSDI, leave all three unchecked)

Check if  statement is TRUE:

*Primary / Regular Veterinarian's Contact information:

This is the Clinic where you take your pet for regular / routine vet care such as vaccinations and dental care. Due to limited funding and how our guidelines are registered with the IRS, we are only able to assist families who already have a regular veterinary clinic.

*The Clinic or Doctor's email is REQUIRED. If you don't know it, please call the Clinic to get it.

Specialty, Emergency or Clinic where services are being performed:

Do not complete this section unless your pet is being referred to an Emergency Clinic, a Specialist or you are taking your pet to a clinic other than your Regular Provider for the services you've requested help with.

*The Referred To Clinic or Doctor's email is REQUIRED if you're being referred. If you don't know it, please call the Clinic to get it.

*Pet Details:

Check this box if you can prove with one of the following that you own the pet in need:

2 Consecutive Rabies Vaccinations OR

Adoption Papers showing the date of adoption OR

Purchase Papers showing the date of purchase

Check this box if your pet is already altered:

If you did NOT check the above box, you must select a reason why your pet is not altered:

Enter the approximate date you acquired your most recently adopted / purchased / found pet (mm/dd/yy:

Please click the Submit button ONLY ONCE.