Veterinary Emergency Medical Assistance Application

Transcription

1 Veterinary Emergency Medical Assistance Application Please make sure to complete this form entirely and to attach the necessary forms required to process your application. If the application is not filled out properly and/or the requested forms are not attached, it may result in denial of your application. Your Information: First and Last Name: Mailing Address: City/State/Zip Code: Daytime Phone Number: Additional Phone Number: Address: Additional Contact, if necessary: Additional Contact s Phone Number: Have you, or a family member, ever received assistance from Open Arms Rescue, Inc? YES If yes, for which pet? Are you applying for assistance for which you were previously denied? YES How many adults are in the household? Children? (under 18) What is your annual household income before taxes?

2 Please describe the circumstances that are preventing you from being able to afford the pet s emergency medical care: Which of the following apply to you? Unemployed Disabled Senior citizen (65 or older) Military veteran/active/spouse None of the above How did you hear about us? Pet s Information: Name of Pet in Question: Species: Breed: Age: Weight: Sex: Spayed/Neutered? YES How long have you assumed responsibility for the pet? Where did you acquire the pet from? What does your pet mean to you and your family?

3 Do you have any other pets? If so, please list species, breed, age, and spayed/neutered status. Pet s Injury Information: Please describe the pet s injury and how it occurred: Approximately when did this occur? Do you have a regular vet? YES If yes, please list their name and address: Which emergency facility did you bring your pet to? Please provide name, address, city/state/zip code, and phone number. Date you brought your pet to the above facility: Name of emergency room veterinarian: What treatment has been provided so far, if any?

4 What treatment still needs to be provided, if any? According to the veterinarian, are the pet s injuries life threatening? (Will the pet die or need to be humanely euthanized within 10 days?) YES Is the pet at the hospital now? YES Is the treatment happening now, scheduled to happen soon, or neither? Did the hospital provide a low and high estimate ranges on the treatment plan? YES If so, what are the low and high estimate ranges? How much have you paid towards the pet s treatment so far, if any? Not including funds already spent or donated, how much can you personally contribute towards the remainder or the treatment/bill? Have you applied for aid through other organizations? YES If you have created an online fundraiser, please provide the link(s) here: Have you applied for Care Credit? YES If approved, how much were you approved for?

5 In order to process your application, please attach a copy of the following documents: Care Credit Approval/Denial Letter Treatment plan from Emergency Veterinary Facility Any Bills Paid, Current Invoice, and/or Documentation of Treatment Provided Thus Far If Able, Please Attach a Photo of the Pet in Question I have read and understand the grant qualifications. I understand that completion of this application does not guarantee financial assistance from Open Arms Rescue, Inc. I solemnly swear that the above information I ve provided is accurate and honest. Signature of Applicant: Date: