Application for Emergency Veterinary Care and/or Diagnostic Testing Assistance

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This form should be used if you are requesting assistance for Emergency, Urgent or Diagnostic Veterinary Care Costs. If you are seeking assistance with Cremation Services, please fill out the Cremation Services Assistance Application.

Applications will be processed within 72 hours of receipt pending vet clinic availability and response time from applicant for requested additional information.

Please be sure to check your email to make sure you received a copy AND watch for an email from a volunteer after we have received your application should we need more information.

Email *

IF YOU BELIEVE YOUR PET'S LIFE IS IN DANGER, YOU SHOULD SEEK IMMEDIATE ASSISTANCE FROM A LICENSED VETERINARIAN.

I UNDERSTAND I MUST TAKE MY PET IN FOR AN INTIAL VISIT PRIOR TO FILLING OUT THIS APPLICATION.

I UNDERSTAND IF I DO NOT TAKE MY PET IN FOR AN INITIAL VISIT PRIOR TO FILLING OUT THIS APPLICATION, MY APPLICATION WILL AUTOMATICALLY BE DENIED.

I UNDERSTAND THE COST OF THE INITIAL VISIT IS AT MY EXPENSE.

I UNDERSTAND MY VET WILL HAVE TO PROVIDE PROOF OF THE DATE OF THE INITIAL VISIT.

I UNDERSTAND I HAVE 14 DAYS FROM THE DATE OF THE INITIAL VISIT TO TURN IN AN APPLICATION.

The initial visit allows the vet to gather information they need to share with us to help us with our review of your application and provide you with the high and low estimate needed for treatment which are required information to complete this application.

Yes

I UNDERSTAND IF I SUBMIT AN INCOMPLETE APPLICATION, IT WILL AUTOMATICALLY BE DENIED AND I MAY NOT RECEIVE NOTICE. *

Yes

Please verify the date your pet was seen by a licensed veterinarian for the initial visit: mm/dd/yyyy

Please provide the name of the veterinary clinic that saw your pet for the initial visit.
*

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