Emergency Outreach Voucher

EMERGENCY OUTREACH VOUCHER

Individual or Couple? *	Individual Couple
Primary First Name *
Primary Last Name *
Primary Phone *
Primary E-mail Address *
Secondary First Name *
Secondary Last Name *
Secondary Phone *
Secondary E-mail
Address *
City *
State *	AR MO OK
Zip Code *
Pet's Name *
Species *	Dog Cat
Date of last vaccines
What's wrong with animal? (Provide as much information as possible.) *
Choose a Vet Clinic *	Bella Vista - Village Animal Hospital Fayetteville - Best Friends Animal Hospital Fayetteville - Cornerstone Animal Hospital Fayetteville - Gulley Park Pet Clinic Fayetteville - Stanton Animal Hospital Huntsville - Huntsville Vet Clinic Lincoln - Lincoln Vet Clinic Rogers - New Hope Animal Clinic Springdale - Springdale Animal Hospital Springdale - St. Francis Animal Hospital
The above clinic should be a vet clinic you have already spoken with or currently use. If not, please verify they are accepting our vouchers and new patients!
If you have it available, please take picture and upload proof of low income. This can be a paystub, social security award letter, disability letter, food stamps, etc. If you don't upload proof thru this form, you will be required to show proof before approval.
Attach proof of income *
Gudelines: HSO: THIS PROGRAM IS ONLY FOR NWA (ARKANSAS) RESIDENTS!!!!! HSO will ensure that only emergency requests will be approved. HSO will also require documentation that the individual is considered low income before being approved for a voucher. HSO will ensure that only 1 pet per address per year will be able to receive a voucher. Vet: Vet agrees to waive their basic exam fee for individual. Vet also agrees that the voucher amount will be used for treatment costs and not for preventative uses. Vets may use their own discretion and deny any voucher they do not deem a true emergency. Individual: The client agrees to pay any amount over the FUNDS provided by HSO. Client also agrees to ensure that the use of this voucher will be only for true emergencies. Client will provide HSO with accurate paperwork to prove they are considered low income for the voucher to be approved.
E-Signature (type full name) *

For Office Use Only:
HSO Rep ESignature: Chase Jackson, President

Please return this voucher with invoices attached to hsoadmin@hsozarks.com