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Application for Financial Assistance. THIS APPLICATION MUST BE COMPLETED BY THE ATTENDING VETERINARIAN!! NO RESPONSE WILL BE PROVIDED TO APPLICATIONS COMPLETED BY OWNERS OR THIRD PARTIES!


Dylan's Hearts is a 501c3 organization funded by contributions by caring individuals. This form must be completed by the attending veterinarian in order for Dylan's Hearts to consider providing financial assistance. Your client should also know that because our vision is larger than our pocketbook, we seldom can provide the total cost of the animal's treatment. Our goal is to be able to offer enough funds for the animal to move forward with treatment while you make other arrangements with your client for the balance due. Thank you for contacting Dylan's Hearts and providing an opportunity to help this animal in need. Thank you also for your help in obtaining financial need documentation of the client.

Please note we do not provide grants for treatment already completed or for diagnostic procedures. Also, please review the eligibility requirements on our website for the family and for the animal needing assistance. In order to meet our fiduciary responsibilities, only those animals with a favorable prognosis will be considered. Thank you.

Date of Application *
Your answer
Untitled Title
Owner's Name and Animal's Name *
Your answer
Age, Gender, Breed of animal. Please indicate if the animal is spayed or neutered. *
Your answer
Please provide detailed description of injury or illness, including when the injury or illness first occurred. *
Your answer
Treatment already provided. *
Your answer
Treatment still needed and itemized estimate detailing cost of treatment. *
Your answer
Prognosis with treatment *
Is the animal receiving treatment in your clinic now: *
Will the animal remain in your clinic until needed treatment is completed? *
In your opinion, will the animal die, need to be euthanized, or surrendered within 10 days if not treated? *
If yes, please explain why.
Your answer
How soon could treatment occur if funds were available? *
Your answer
Name of Veterinary Hospital and Attending Veterinarian. *
Your answer
Address of veterinary clinic, including city and state. *
Your answer
Telephone number of veterinary hospital. *
Your answer
Email address of veterinary hospital *
Your answer
Name of contact person at your hospital regarding this application for assistance. *
Your answer
Have you previously provided routine exams and vaccinations for this animal? If so, how long have you been seeing the animal? *
Your answer
The owner will automatically qualify for financial assistance if proof is provided for any of the following.Social Security Disability cannot exceed the WIC Guidelines for eligibility. Check those that apply. PROOF OF DOCUMENTATION MAY BE EMAILED TO DONNA@DYLANSHEARTS.COM. *
We follow the WIC Income Eligibility Guidelines to help determine if someone who does not meet the above criteria is eligible for financial assistance. Please provide number of people in household. *
Your answer
What is the annual income of the household? *
If the client is not part of any circumstances above, but has personal circumstances that have created need for assistance, please explain.
Your answer
Does your office accept Care Credit? *
If yes, did this person apply at your office? *
If yes, what was the result?
If approved by Care Credit, what was the limit of assistance provided?
Your answer
Owner of animal agrees that if funds are granted those funds will go directly to the veterinarian who will perform the services on their animal companion. In addition, the owner grants permission to Dylan's Hearts to use photos and information of their animal companion for promotional purposes. *
If you have any questions, please call Dylan's Hearts at 336-365-2334 or email to donna@dylanshearts.com
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