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* 1. First Name

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* 2. Last Name

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* 3. Address

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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 

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

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* 8. What is the veterinarian recommending?

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

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* 10. Do you have pet insurance?

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* 11. What amount can you pay?

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* 12. Have you applied for CareCredit?

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

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* 14. Are you employed?

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

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* 16. What is your household monthly income?

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* 17. Have you secured any funding from others?

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* 18. If you answered YES please explain.

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* 19. Please explain your need for financial assistance in detail.

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

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* 21. Please attach a photo of your pet.

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

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

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* 23. Signature

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* 24. Date/Time

Date
Time
Thank you for applying for assistance.  Please allow 24-48 hours for a response. 
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.

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