Hero fund request

Application for financial assistance for pet medical care (must be Pets for Patriots adoptee). Please note that we do not provide funding for emergency or urgent medical care, or veterinary services that have already been paid.

Further, this support is temporary and application does not guarantee approval.

Your contact details

First Name

Last Name

Email

Phone number

###-###-####

Street address

City

State

Zipcode

Your pet's information

Pet's name

What is your pet's medical problem or issue (15 words max)

Please tell us the medical issue or diagnosis for which you are requesting financial support.

Additional details (15 words max)

Please provide any details that may help us make a decision on this request. Be clear, but brief.

How soon does your pet require medical treatment?

Tell us the timing of this medical need. Please note that we cannot fund emergency or urgent care.

Your veterinarian's information

Name of veterinary practice (business name) treating your pet

Phone of veterinary practice

###-###-####

First name of practice/office manager

Last name

First name of veterinarian treating your pet:

Last name

Estimate

The amount estimated for care requested, if you have received one; use whole dollar amounts only ($80 not $80.50).

Almost done!

Permission for veterinarian(s) to share information

By checking this box, I confirm that I have given my pet's veterinarian(s) permission to share all medical information with Pets for Patriots, including but not limited to medical records, estimates, care plans, test results, medical opinions, and prognoses.

Consent

I grant Pets for Patriots full access to my pet's medical records, including but not limited to estimates, treatment plans, doctor notes, test results, medical opinions, and prognoses.

I agree to the Terms of Use

Picture(s)

Accepted file types: jpg, png, gif. Max file size 50MB, max files: 3. If you are granted support from our hero fund we may use picture(s) of you and your pet to generate support from our donors and/or to update them on your pet's progress. You will be identified on a first-name basis only (e.g., Sam and Fluffy).

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Contact Information

Hero fund request

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