Application for Financial Assistance

Helping humans enrich animals’ lives

Step 1 of 6

🐾 Pet information

Name of pet *

Please enter your pet’s name.

Name of pet owner *

Please enter your full name.

Phone *

Please enter a phone number.

Email *

Please enter a valid email.

Address *

Please fill in your address.

🐶 About your pet

Type of pet *

Please enter the type of pet.

Breed *

Please enter the breed.

Age of pet *

Please enter your pet’s age.

Date of birth

Weight *

Please enter your pet’s weight.

Gender *

Male Female

Please select a gender.

Spayed or neutered? *

Yes No

Please select an option.

Pet insurance? *

Yes No

Please select an option.

Pet photo

📷

Choose a photo or drag and drop

JPG, PNG up to 10MB

🏥 Veterinary information

Referring veterinary practice *

Please enter the practice name.

Referring RDVM *

Please enter the RDVM name.

Describe the medical condition *

Please describe the medical condition.

Describe the treatment plan *

Please describe the treatment plan.

Treatment cost *

Please enter the cost.

Amount you can pay before hardship *

Please enter an amount.

Discussed a payment plan with your vet? *

Yes, but it is still a hardship No

Please select an option.

💰 Financial information

Applying to Care Credit is a requirement for eligibility. Visit carecredit.com or call 800-677-0718.

Have you applied for and received Care Credit? *

Please select an option.

Did you apply for a Scratch Pay loan? *

Yes No

Please select an option.

Household size *

Please enter household size.

Estimated monthly household income *

Please enter your income.

Estimated fully liquid assets *

Cash/bank accounts/securities only. Does not include 401K, real estate, or physical property.

Please enter your liquid assets.

Describe how this treatment is a significant financial hardship *

Please describe your hardship.

Are you on government assistance? *

Yes No

Please select an option.

📄 Documents

Files upload directly to Dropbox — they never touch the web server. Links are saved automatically to your Google Sheet.

Do you file income taxes? *

Yes No

Please select an option.

Why have you chosen not to file taxes?

First and last pages of your most recent income tax return

📋

Choose files or drag and drop

PDF or images accepted

Proof of monthly income

💵

Choose files or drag and drop

Pay stubs, bank statements, etc.

Proof of monthly income for all household members (if employed)

👥

Choose files or drag and drop

PDF or images accepted

Proof of Care Credit denial or loan amount

💳

Choose files or drag and drop

PDF or images accepted

✅ Review & submit

Photo use permission *

I grant Guardian HEALS the 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.

Please confirm this to continue.

Date *

Please enter today’s date.

✅

Application submitted!

Thank you — the Guardian HEALS team will review your application and be in touch soon.

Please check your email for a confirmation.