Veterinary Assistance Application - 2024
Veterinary Assistance Application - 2024
Email *
First Name *
Last Name *
Street Address *
County *
City *
State *
Zip Code *
Mailing address if different from above *
Mobile Phone *
Email  *
Are you a full-time resident of Kauai? *
Is the pet in need owned by you? *
What species is your pet? *
Age of pet *
How long have you owned your pet? *
Name of your pet's regular veterinarian (if applicable) *
Name of diagnosing veterinarian and vet practice *
KSPCA can only reimburse costs directly to partner vet clinics. Are you willing to use one of KSPCA's partner vets? *
How many dogs do you own? *
How many dogs live in household? *
How many cats do you own? *
How many cats live in household? *
Are all your pets spayed/neutered? *
If no, tell us why not? *
KSPCA requires that the pet in need be altered either before or after the requested medical care. Are you will to do this? *
Please tell us about the critical veterinary services you need financial assistance with: *
What is the estimated cost of treatment? *
Do you have pet insurance for the pet in need? *
How much, if anything, can you pay the vet when services are rendered? *
Would you be willing/able to sign up for a payment plan? *
How much are you comfortable paying monthly? *
Name of Employer (state unemployed if applicable) *
What was the reported annual income for your household on your tax return last year? *
What was the reported annual income for your household on your tax return 2 years ago? *
Do you have dependents? If so, please list names and ages. *
Where does your pet live (indoors/outdoors/on a tether, etc)? *
What is your plan for your pet's care after treatment? *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Kauai Society for the Prevention of Cruelty to Animals.

Does this form look suspicious? Report

Google Forms