Request for Financial Assistance

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1. First Name (Required.)

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2. Last Name (Required.)

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3. Address (Required.)

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Country *

Email Address *

Phone Number *

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4. Pet's Name (Required.)

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5. Name of Veterinary Hospital (Required.)

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6. Address of Veterinary (Required.)

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code

Phone Number *

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7. Have you received a diagnosis/stage/prognosis from the veterinarian? (Required.)

Yes

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8. What is the veterinarian recommending? (Required.)

Additional Tests-including blood, stool, X-Ray, MRI, or other

Surgery

Chemo/Radiation

Euthanasia

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9. Have you received an estimate from the veterinarian? (Required.)

Yes

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10. Please attach a copy of estimate from your veterinary hospital.

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11. Do you have pet insurance? (Required.)

Yes

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12. What amount can you pay? (Required.)

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13. Have you applied for CareCredit? (Required.)

Yes

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14. If you answered YES how much have you been approved to receive?

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15. Are you employed? (Required.)

Yes

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16. If you answered NO are you receiving unemployment?

Yes

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17. What is your household monthly income? (Required.)

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18. Have you secured any funding from others?

Yes

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19. If you answered YES please explain.

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20. Please explain your need for financial assistance in detail. (Required.)

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21. How did you hear about Lucy the Rescue Dog Inc.? (Required.)

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22. Please attach a photo of your pet. (Required.)

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23. I authorize Lucy the Rescue Dog Inc. to use photos/videos of me/my pet on their website and social media. (Required.)

Approve

Disapprove

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24. Signature (Required.)

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25. Date/Time (Required.)

Date / Time

Date

Time

AM/PM

Disclosure: There is never any guarantee that Lucy the Rescue Dog Inc. will be able to provide financial assistance. If this is an emergency situation, where a delay will put their life at risk, it is your responsibility to seek critical care for that animal immediately.

Request for Financial Assistance

Question Title

* 1. First Name (Required.)

Question Title

* 2. Last Name (Required.)

Question Title

* 3. Address (Required.)

Question Title

* 4. Pet's Name (Required.)

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* 5. Name of Veterinary Hospital (Required.)

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* 6. Address of Veterinary (Required.)

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* 7. Have you received a diagnosis/stage/prognosis from the veterinarian? (Required.)

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* 8. What is the veterinarian recommending? (Required.)

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* 9. Have you received an estimate from the veterinarian? (Required.)

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* 10. Please attach a copy of estimate from your veterinary hospital.

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* 11. Do you have pet insurance? (Required.)

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* 12. What amount can you pay? (Required.)

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* 13. Have you applied for CareCredit? (Required.)

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* 14. If you answered YES how much have you been approved to receive?

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* 15. Are you employed? (Required.)

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* 16. If you answered NO are you receiving unemployment?

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* 17. What is your household monthly income? (Required.)

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* 18. Have you secured any funding from others?

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* 19. If you answered YES please explain.

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* 20. Please explain your need for financial assistance in detail. (Required.)

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* 21. How did you hear about Lucy the Rescue Dog Inc.? (Required.)

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* 22. Please attach a photo of your pet. (Required.)

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* 23. I authorize Lucy the Rescue Dog Inc. to use photos/videos of me/my pet on their website and social media. (Required.)

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* 24. Signature (Required.)

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* 25. Date/Time (Required.)

1. First Name (Required.)

2. Last Name (Required.)

3. Address (Required.)

4. Pet's Name (Required.)

5. Name of Veterinary Hospital (Required.)

6. Address of Veterinary (Required.)

7. Have you received a diagnosis/stage/prognosis from the veterinarian? (Required.)

8. What is the veterinarian recommending? (Required.)

9. Have you received an estimate from the veterinarian? (Required.)

10. Please attach a copy of estimate from your veterinary hospital.

11. Do you have pet insurance? (Required.)

12. What amount can you pay? (Required.)

13. Have you applied for CareCredit? (Required.)

14. If you answered YES how much have you been approved to receive?

15. Are you employed? (Required.)

16. If you answered NO are you receiving unemployment?

17. What is your household monthly income? (Required.)

18. Have you secured any funding from others?

19. If you answered YES please explain.

20. Please explain your need for financial assistance in detail. (Required.)

21. How did you hear about Lucy the Rescue Dog Inc.? (Required.)

22. Please attach a photo of your pet. (Required.)

23. I authorize Lucy the Rescue Dog Inc. to use photos/videos of me/my pet on their website and social media. (Required.)

24. Signature (Required.)

25. Date/Time (Required.)