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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 *
Untitled Title
Owner's Name and Animal's Name *
Age, Gender, Breed, and weight of animal. Please indicate if the animal is spayed or neutered. *
Please provide detailed description of injury or illness, including when the injury or illness first occurred. *
For request for assistance for treatment of tumors/masses, please provide the following information: 1) Describe size and location of mass, and 2) fine needle aspirate is required. Please provide results.
Treatment already provided. *
Treatment still needed and itemized estimate detailing cost of treatment. *
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.
How soon could treatment occur if funds were available? *
Name of Veterinary Hospital and Attending Veterinarian. *
Address of veterinary clinic, including city and state. *
Telephone number of veterinary hospital. *
Email address of veterinary hospital *
Name of contact person at your hospital regarding this application for assistance. *
Have you previously provided routine exams and vaccinations for this animal? If so, how long have you been seeing the animal? *
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. *
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.
Does your office accept Care Credit or a similar lending program? *
If yes, did this person apply at your office? *
If yes, what was the result?
Clear selection
If approved by Care Credit, or another lending program, what was the limit of assistance provided?
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 843-855-2381 or email to
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