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Application for Financial Assistance
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Application for Financial Assistance
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Name of Pet
*
Name of Pet Owner
*
First
Last
Phone
*
Email
*
Address
*
Address Line 1
Address Line 2
City
— Select state —
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
State
Zip Code
Type of Pet
*
Age of Pet
*
Pet’s Date of Birth
*
Pet Gender
*
Male
Female
Unknown
Spayed or Neutered
*
Yes
No
Unknown
Do You Have Pet Insurance
*
Yes
No
Not sure
Pet’s breed
*
Pet’s weight
*
Referring Veterinary Practice
*
Referring RDVM
*
Describe the medical condition your pet is currently suffering from. Please note if this is a chronic or acute condition and when it started.
*
Describe the treatment plan for your pet.
*
How much will this treatment cost
*
How much can you pay for this treatment before it becomes an extremely significant financial hardship
*
Have you discussed a payment plan with your veterinarian
*
Yes
No
Applying to Care Credit carecredit.com or 800-677-0718 is a requirement for eligibility. Have you applied for and received Care Credit
*
Yes, approved
Yes, denied
Applied, pending decision
No
How many people are in your household
*
Provide the estimated monthly income of all adult members of your household
*
Provide an estimate of fully liquid assets of your household Fully liquid assets are cash on hand or in the bank including savings and checking accounts and any easily sellable securities. It does not count 401K savings college funds real estate or physical property
*
Describe briefly how paying for this treatment is a significant financial hardship.
*
and of denial
Are you or anyone in your family disabled a veteran andor sick
*
Yes
No
Pet Image
*
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Do you file income taxes
*
Yes
No
If no why have you chosen to not file taxes
*
Please upload the first and last pages of your most recent income tax return.
*
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Did you apply for a Care Credit loan This is required.
*
Yes
No
Please upload your proof of Care Credit denial or loan amount.
*
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Did you apply for a Scratch Pay loan
*
Yes
No
Please upload your proof of Scratch Pay denial or loan amount.
*
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Choose Files to Upload
Please provide proof of monthly inocme.
*
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Please provide proof of monthly income if employed for all members of your household.
*
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Choose Files to Upload
Are you on government assistance
*
Yes
No
Please provide proof of government assistance with the monthly income.
*
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Choose Files to Upload
I grant Guardian Heals the future right to use my pet's name, image, and story in promotional materials. I understand that I will be contacted again to confirm if GH chooses to do so.
*
Permission
Date
*
Submit