Application For Dog Medical Financial Help
Date of application
Name of Person Applying
Owner (s) First and Last Name
Email
Home Address (Please add City, State and Zip Code) *
Contact Number
Employer (If currently working)
Work Number
Dog's Name
Breed
Spayed/Neutered
Vaccines Current
Dog's Birthday
Acquired Pet From
Pet Insurance
Has your Dog been seen by a veterinarian and diagnosed with an emergency
Name(s) of Veterinary Hospital and Primary Veterinarian, Address and Contact numbers
What is the nature of your dog's injury or illness?
Do you have accounts in any other charitable systems? (We highly support other sources of donations such as GoFundMe accounts)
Do you have an Instagram and/or Facebook account? If yes, please list
Nature of Financial Hardship (Please be specific)
Are the funds you are inquiring about needed for an upcoming surgery or treatment, or has the medical care already been given?
Where did you learn of Paw Philanthropy?
Have you applied to Paw Philanthropy Before?
If yes, date and where you approved or not approved, please provide details.
I declare that I have exhausted all alternative options available to me for financial assistance, however, I agree to reimburse the Paw Philanthropy for any funds received upon a change in my financial circumstances. In addition, I hereby assign to the Paw Philanthropy all rights to any amounts received from insurance or other source of recovery related to this matter. I do not operate any form of breeding facility for profit and agree to provide any documents needed in support of this request. I understand that the Paw Philanthropy is not responsible for the treatment and/or result of any veterinary services provided and hereby waive any and all claims for liability against the Paw Philanthropy, and that the Paw Philanthropy hereby reserves the right to deny a Request for Financial Assistance to anyone for any reason. I understand that Paw Philanthropy is not financially responsible for charges incurred at the treating veterinary hospital prior to the submission of this application. I understand that if I am approved for funding, I am not automatically approved for any further assistance. I authorize the Paw Philanthropy to use my and/or my pet’s photograph and any information relating to the payment of funds pursuant to this application for any purpose. I understand and agree for Paw Philanthropy to contact and validate the information provided. I acknowledge that approved funds will be paid DIRECTLY to my veterinarian/veterinary hospital. I declare, under penalty of perjury, that the foregoing is true and correct to the best of my knowledge. I also agree that any funds provided and not used will be transferred back to Paw Philanthropy from the Veterinary Hospital or Vet.
If you selected Yes, please print your full name and it will be recognized as a formal signature for accepting policies, allowing us authorization and everything else above.
Date Signed
Submit
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