Hero fund request Home Veterans 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. Your contact details First Name Last Name Email Phone number ###-###-#### Street address City StatePlease select... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Puerto Rico Virgin Island Northern Mariana Islands Guam American Samoa Palau 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? Please select... Within the next 6 months Within the next month Within the next 1-2 weeksTell 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 informationBy 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. ConsentI 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). Honeypot Contact Information
