Request for Financial Assistance

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* 1. First Name

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* 2. Last Name

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* 3. Address

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Country *

Email Address *

Phone Number *

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* 4. Pet's Name

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* 5. Name of Veterinary Hospital

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* 6. Address of Veterinary

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?

Yes

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* 8. What is the veterinarian recommending?

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?

Yes

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

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

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* 11. Do you have pet insurance?

Yes

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* 12. What amount can you pay?

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* 13. Have you applied for CareCredit?

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?

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?

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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.

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

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* 22. Please attach a photo of your pet.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

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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.

Approve

Disapprove

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* 24. Signature

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* 25. Date/Time

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.