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.

Name*
First Last
Email*
Phone*
Address*
Street Address City State ZIP Code
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?*
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 veterinarian treating your pet*
First Last
This is the name of the actual veterinary doctor treating your pet
Estimate
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*
I agree
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 estimates, treatment plans, doctor notes, test results, etc.
I grant Pets for Patriots full access to my pet's medical records, including but not limited to medical records, estimates, care plans, test results, medical opinions, and prognoses; to speak directly with my pet's treating veterinarian(s) and related medical professionals; and to negotiate payment and make payment in full or part on my behalf. Further, I understand that application does not guarantee approval.
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*
- I agree to the Terms and Conditions
Name
This field is for validation purposes and should be left unchanged.

Hero Fund request

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