Application for Financial Aid Name * First Name Last Name Name of Veterinary Clinic/Hospital * Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Has a veterinarian determined that with treatment, your pet has a favorable prognosis? * Yes No Name of Veterinary Clinic/Hospital where your pet is being treated * Vet's Specialty * Canine and feline Shelter medicine Feline Canine Virology Immunology Bacteriology/Mycology Parasitology Anatomic pathology Clinical pathology Epidemiology Radiation oncology Small animal surgery Cardiology Small animal internal medicine Neurology Oncology Nutrition Name of Licensed Attending Veterinarian * First Name Last Name Clinic’s or Vet’s Email * Clinic's or Vet’s Phone Number * (###) ### #### Clinic’s or Vet’s Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Diagnosis * What is your pet diagnosed with? Describe the medical problem and treatment * Last Date of Care * MM DD YYYY Animal's Name * First Name Last Name Animal Type * Dog Cat Animal's Breed * Animal's Age * Total Invoice Amount * $ Have you applied for CareCredit or Scratchpay? * Yes No Were you approved? * Yes No Amount of CareCredit or Scratchpay approved * $ Total amount already paid towards the cost of the current invoice for the animal's treatment * $ How much have you secured in donations through fundraising sites or other organizations? * $ Do you have pet insurance? * Yes No If you have pet insurance, how much will your policy reimburse? * $ Have you asked the veterinary clinic or hospital for a discount? * Yes No How much of a discount is the hospital willing to provide? * Percentage (%) or Dollar ($) Amount How did you hear of us? Search Engine Social Media Client Testimonial Email Newsletter Referral Other What is your budget? * $ Total amount requested from Treasured Pets * (Not to exceed $3,500) $ Is there anything else you'd like to share? Thank you! Someone from our staff will get back to you within three (3) days.
