The purpose of this form is to collect request information in the event that Healing Heartworm treatment assistance were to become available. At this time, there is no open grant for Heartworm treatment. Information provided within this request form A) expresses your interest in being contacted should funding become available in the future and B) informs us of the need at this time in order for us to tailor any future grant opportunities. 

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* 1. Contact Info

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* 2. Organization Type:

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* 3. TAX ID

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* 4. Are you a member in our Partners for Pets network? 

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* 5. Have you been funded previously by BPF? 

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* 6. Please describe your need for heartworm treatment support:

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* 7. How many animals in your care are currently in need of treatment?

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* 8. What is your (your vet's) standard treatment process? (Please be detailed) 

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* 9. Through what method do you treat?

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* 10. Do you have access to treatment around $200/pet? 

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* 11. What is your average cost for total treatment for one dog? ($ Amount Only)

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* 12. Please describe the above average cost:

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* 13. If BPF were unable to provide financial assistance but were able to provide free Imoxi would you be interested in receiving AND able to administer it?

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* 14. What is your current heartworm treatment budget like? What fundraising are you doing for heartworm treatment? What issues are you facing? 

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