Name * Email *
Phone * Address
* Pet's Name * What is your pet's medical problem or issue? *
Please tell us about the medical issue or diagnosis for which you are requesting financial support.
Additional details *
Please provide any details that may help us make a decision on your case. Be clear, but brief.
How soon does your pet require medical treatment? * Within next 6 months Within the month Within next 1-2 weeks Ongoing
Tell us the timing of this medical need. Please note that we cannot fund emergency or urgent care.
Name of veterinary practice treating your pet *
This is the name of the veterinary hospital or clinic that is treating your pet
Phone of veterinary practice * Name of practice, hospital, or office manager *
This is the name of the office staff member who manages the veterinary practice
Name of veterinarian treating your pet *
This is the name of the actual veterinary doctor treating your pet
If you have already received an estimate for care, please tell us the amount; use whole dollar amounts only ($80 not $80.50)
Permission for veterinarian(s) to share information * Consent * Picture(s) *
Drop files here or
Accepted file types: jpg, png, gif, Max. file size: 50 MB, 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. You will be identified on a first-name basis only (e.g., Sam and Fluffy).
Terms and Conditions * Comments
This field is for validation purposes and should be left unchanged.