Financial Assistance Application - Dylan's Hearts


THIS APPLICATION MUST BE COMPLETED BY THE VETERINARIAN!! NO RESPONSE WILL BE MADE TO THOSE APPLICATIONS NOT COMPLETED BY THE ATTENDING VETERINARY HOSPITAL!!!!

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 your for contacting Dylan's Hearts and providing an opportunity to help this animal in need.

THANK YOU FOR YOUR HELP IN OBTAINING FINANCIAL NEED DOCUMENTATION OF THE CLIENT.


APPLICATION MUST BE COMPLETED BY THE VETERINARIAN!! NO RESPONSE WILL BE PROVIDED TO ANY APPLICATION NOT COMPLETED BY THE VETERINARIAN! ANY FUNDS COMMITTED FOR A GRANT WILL BE HELD FOR 30 DAYS. IF TREATMENT CANNOT BE COMPLETED WITHIN 30 DAYS, PLEASE NOTIFY DYLAN'S HEARTS AND PROVIDE CIRCUMSTANCES FOR THE DELAY. OTHERWISE, THE FUNDS COMMITTED WILL BE RETURNED TO OUR GENERAL ACCOUNT, AND THE GRANT WILL NOT BE HONORED. THANK YOU!
Untitled Title
Date of Application
Your answer
Name of Veterinary Hospital
Your answer
Name of attending veterinarian
Your answer
Address of veterinary hospital
Your answer
Veterinary hospital telephone number
Your answer
Email address of veterinary hospital
Your answer
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 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.
Number of people in Household?
Your answer
What is the annual income of the household?
Please choose the income range below for the household.
If the client is not part of the circumstances above, but has personal circumstances that have created need for assistance, please explain.
Your answer
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
Clinic hours
Your answer
Owner's name and name of animal
Your answer
Age and breed of animal
Your answer
Please provide description of injury or illness.
Your answer
Prognosis with treatment
Your answer
Treatment already provided
Your answer
Treatment still needed and itemized cost of treatment
Your answer
In your opinion, will the animal die or need to be euthanized within 10 days if not treated?
If yes, explain why.
Your answer
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 animal spayed or neutered?
If no, can they be spayed or neutered now?
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 336-365-2334, or email to donna@dylanshearts.com
Your answer
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