Stella's Touch application
Please complete this application, answering all questions completely, and submit.  You will receive a call from our staff upon receipt of your application.
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Today's date *
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Owner's Full Name *
Address (including city and state) *
Phone number *
Email address *
Have you applied for Care Credit? *
If you were approved for Care Credit, what is the amount of credit for which you were approved?
Pet's name *
Pet's breed *
Pet's age *
Is your pet spayed or neutered? *
If your pet is not spayed or neutered, why not? *
Is your pet up to date on core vaccines (rabies, distemper, parvo)? *
If you pet is not up to date on vaccines, why not? *
What is your pet's health concern for which you are seeking funding? *
Has your pet been seen by a veterinarian for this condition? *
What is your veterinarian's diagnosis of the current condition? *
Has your veterinarian provided a treatment plan and estimate for the current condition?  If so, please explain and provide the estimate cost. *
Your employer *
Current monthly household income (including all people who live in your home) *
Are you receiving any type of public assistance?  Check all that apply. *
Required
How much are you able to contribute to this vet visit or treatment? *
Your veterinarian's name and phone number
Do you have an appointment scheduled with your veterinarian?  If so, provide date and time. *
Do you give permission to Paws-Ability to contact your veterinarian to obtain information about your pet's health and treatment?
**We require that permission be granted to speak with your veterinarian's office regarding your pet's condition.
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