Furry Friend's Fund Financial Assistance Application
IN ORDER TO BE APPROVED, THIS APPLICATION MUST BE COMPLETED BY THE VETERINARIAN.
APPLICATIONS MAY TAKE UP TO 48 HOURS TO PROCESS.
Date of Application *
Your answer
Name of Veterinary Hospital *
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Name of Attending Veterinarian *
Your answer
Address of Veterinary Hospital *
Your answer
Veterinary Hospital Telephone Number *
Your answer
Veterinary Hospital Email Address or Website
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Clinic Hours *
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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
If you have not previously cared for this animal, please provide name and phone number of the veterinarian(s) seen for routine exams and vaccinations where we can call to verify animal care history over the past 1-3 years. *
Your answer
The owner will automatically qualify for financial assistance if proof is provided for any of the following. Check those that apply. PROOF OF DOCUMENTATION MAY BE EMAILED TO ASSISTANCE@HSPIEDMONT.ORG *
We follow the WIC Income Eligibility Guidelines to help determine if someone who does not meet the above criteria is eligible for financial assistance. Number of people in Household? *
Your answer
What is the annual income of the household? *
Your answer
If the client is not part of the circumstances above, but has personal circumstances that have created need for assistance, please explain.
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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 is the amount of assistance provided?
Your answer
Owner Name *
Your answer
Pet's Name *
Your answer
Pet's Age *
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Pet's Breed *
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Please provide description of injury or illness. *
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Prognosis with treatment *
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Treatment already provided *
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Treatment still needed and itemized cost of treatment *
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In your opinion, will the animal die or need to be euthanized within 10 days if not treated? *
If yes, explain why.
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Is the animal receiving treatment in your clinic now? *
Will the animal remain in your clinic until needed treatment is completed? *
How soon could treatment occur if funds were available? *
Your answer
What is the longest the animal can wait for treatment? *
Your answer
Is the pet spayed or neutered? *
If no, can they be spayed or neutered now? *
Owner of animal agrees that if funds are granted those funds will be paid directly to the veterinarian who will perform the services on their pet. In addition, the owner grants permission to the Humane Society of the Piedmont to use photos and information of their pet for promotional purposes. *
If you have any questions, please call the Humane Society of the Piedmont at 336-299-3060, or email assistance@hspiedmont.org
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