Vet Emergency Assistance Application

If we have available resources, we can provide financial assistance for family pets suffering from severe illnesses or injuries to be evaluated by a vet. After the initial exam, treatments will be the owner's responsibility. To qualify, you must demonstrate financial need. This application is not for routine vet care and we will not process applications requesting a vet visit without having an immediate medical need.

Application for Vet Emergency Assistance

First Name *
Last Name *
Home Address *
City *
State *
County *
Zip Code *
Phone Number *
E-Mail *
Number of Adults in Household *
Number of Children in Household * If no children in household, please put none or 0.
Total MONTHLY Household Income * Please include all sources of income.
What public assistance do you receive? *
Proof of Income Please provide a photo of proof of income or assistance (pay stub, bank statement, entitlement letter, or copy of an EBT card). Take a photo, click "choose file" and select photo to upload.
Has your animal ever been seen by a vet? If no, please explain why. *
Is the pet up to date on yearly vaccines? *	NoYes
Which vet do you take your animals to?
Veterinary's Phone Number
Pet Name *
Cat or Dog? *	Cat Dog
Is your pet male or female? *	Male Female
Is your pet spayed or neutered? If not, please explain why *
Age of Pet *
Medical Issue: * Please explain the current medical situation with your pet, and any other relavent information.
Optional: Please provide a photo of the medical issue if visible If the current issue is visible, please provide a picture if you are able.
I understand that this application does not guarantee assistance and understand it is ultimately my reponsibility to get emergency care for my pet if help is not available. *	NoYes