{"id":85,"date":"2026-02-16T13:16:45","date_gmt":"2026-02-16T13:16:45","guid":{"rendered":"https:\/\/healspets.org\/?page_id=85"},"modified":"2026-02-16T13:19:41","modified_gmt":"2026-02-16T13:19:41","slug":"application-for-financial-assistance","status":"publish","type":"page","link":"https:\/\/healspets.org\/?page_id=85","title":{"rendered":"Application For Financial Assistance"},"content":{"rendered":"<style id=\"wpforms-css-vars-43-block-0371e6af-5544-46eb-889c-d67547ccaf86\">\n\t\t\t\t#wpforms-43.wpforms-block-0371e6af-5544-46eb-889c-d67547ccaf86 {\n\t\t\t\t--wpforms-field-size-input-height: 43px;\n--wpforms-field-size-input-spacing: 15px;\n--wpforms-field-size-font-size: 16px;\n--wpforms-field-size-line-height: 19px;\n--wpforms-field-size-padding-h: 14px;\n--wpforms-field-size-checkbox-size: 16px;\n--wpforms-field-size-sublabel-spacing: 5px;\n--wpforms-field-size-icon-size: 1;\n--wpforms-label-size-font-size: 16px;\n--wpforms-label-size-line-height: 19px;\n--wpforms-label-size-sublabel-font-size: 14px;\n--wpforms-label-size-sublabel-line-height: 17px;\n--wpforms-button-size-font-size: 17px;\n--wpforms-button-size-height: 41px;\n--wpforms-button-size-padding-h: 15px;\n--wpforms-button-size-margin-top: 10px;\n--wpforms-container-shadow-size-box-shadow: none;\n\t\t\t}\n\t\t\t<\/style><div class=\"wpforms-container wpforms-container-full wpforms-container-quiz wpforms-block wpforms-block-0371e6af-5544-46eb-889c-d67547ccaf86 wpforms-render-modern\" id=\"wpforms-43\"><form id=\"wpforms-form-43\" class=\"wpforms-validate wpforms-form\" data-formid=\"43\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F85&#038;wpforms_form_id=43\" data-token=\"e6cf24a3d2b89720c986feae964d578b\" data-token-time=\"1775397398\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div id=\"wpforms-error-noscript\" style=\"display: none;\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-43-field_1-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"1\"><label class=\"wpforms-field-label\" for=\"wpforms-43-field_1\">Name of Pet <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-43-field_1\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][1]\" aria-errormessage=\"wpforms-43-field_1-error\" required><\/div><div id=\"wpforms-43-field_2-container\" class=\"wpforms-field wpforms-field-name\" data-field-type=\"name\" data-field-id=\"2\"><label class=\"wpforms-field-label\" for=\"wpforms-43-field_2\">Name of Pet Owner <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-43-field_2\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][2]\" aria-errormessage=\"wpforms-43-field_2-error\" aria-describedby=\"wpforms-43-field_2-description\" required><div id=\"wpforms-43-field_2-description\" class=\"wpforms-field-description\">First &amp; Last<\/div><\/div><div id=\"wpforms-43-field_3-container\" class=\"wpforms-field wpforms-field-phone\" data-field-type=\"phone\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-43-field_3\">Phone <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-43-field_3\" class=\"wpforms-field-medium wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][3]\" aria-label=\"Phone\" aria-errormessage=\"wpforms-43-field_3-error\" required><\/div><div id=\"wpforms-43-field_4-container\" class=\"wpforms-field wpforms-field-email\" data-field-type=\"email\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-43-field_4\">Email <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-43-field_4\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][4]\" spellcheck=\"false\" aria-errormessage=\"wpforms-43-field_4-error\" required><\/div><div id=\"wpforms-43-field_5-container\" class=\"wpforms-field wpforms-field-address\" data-field-type=\"address\" data-field-id=\"5\"><fieldset><legend class=\"wpforms-field-label\">Address <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-43-field_5\" class=\"wpforms-field-address-address1 wpforms-field-required\" name=\"wpforms[fields][5][address1]\" aria-errormessage=\"wpforms-43-field_5-error\" required><label for=\"wpforms-43-field_5\" class=\"wpforms-field-sublabel after\">Address Line 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-43-field_5-city\" class=\"wpforms-field-address-city wpforms-field-required\" name=\"wpforms[fields][5][city]\" aria-errormessage=\"wpforms-43-field_5-city-error\" required><label for=\"wpforms-43-field_5-city\" class=\"wpforms-field-sublabel after\">City<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><select id=\"wpforms-43-field_5-state\" class=\"wpforms-field-address-state wpforms-field-required\" name=\"wpforms[fields][5][state]\" aria-errormessage=\"wpforms-43-field_5-state-error\" required><option class=\"placeholder\" value=\"\" selected disabled>&#8212; Select state &#8212;<\/option><option value=\"AL\" >Alabama<\/option><option value=\"AK\" >Alaska<\/option><option value=\"AZ\" >Arizona<\/option><option value=\"AR\" >Arkansas<\/option><option value=\"CA\" >California<\/option><option value=\"CO\" >Colorado<\/option><option value=\"CT\" >Connecticut<\/option><option value=\"DE\" >Delaware<\/option><option value=\"DC\" >District of Columbia<\/option><option value=\"FL\" >Florida<\/option><option value=\"GA\" >Georgia<\/option><option value=\"HI\" >Hawaii<\/option><option value=\"ID\" >Idaho<\/option><option value=\"IL\" >Illinois<\/option><option value=\"IN\" >Indiana<\/option><option value=\"IA\" >Iowa<\/option><option value=\"KS\" >Kansas<\/option><option value=\"KY\" >Kentucky<\/option><option value=\"LA\" >Louisiana<\/option><option value=\"ME\" >Maine<\/option><option value=\"MD\" >Maryland<\/option><option value=\"MA\" >Massachusetts<\/option><option value=\"MI\" >Michigan<\/option><option value=\"MN\" >Minnesota<\/option><option value=\"MS\" >Mississippi<\/option><option value=\"MO\" >Missouri<\/option><option value=\"MT\" >Montana<\/option><option value=\"NE\" >Nebraska<\/option><option value=\"NV\" >Nevada<\/option><option value=\"NH\" >New Hampshire<\/option><option value=\"NJ\" >New Jersey<\/option><option value=\"NM\" >New Mexico<\/option><option value=\"NY\" >New York<\/option><option value=\"NC\" >North Carolina<\/option><option value=\"ND\" >North Dakota<\/option><option value=\"OH\" >Ohio<\/option><option value=\"OK\" >Oklahoma<\/option><option value=\"OR\" >Oregon<\/option><option value=\"PA\" >Pennsylvania<\/option><option value=\"RI\" >Rhode Island<\/option><option value=\"SC\" >South Carolina<\/option><option value=\"SD\" >South Dakota<\/option><option value=\"TN\" >Tennessee<\/option><option value=\"TX\" >Texas<\/option><option value=\"UT\" >Utah<\/option><option value=\"VT\" >Vermont<\/option><option value=\"VA\" >Virginia<\/option><option value=\"WA\" >Washington<\/option><option value=\"WV\" >West Virginia<\/option><option value=\"WI\" >Wisconsin<\/option><option value=\"WY\" >Wyoming<\/option><\/select><label for=\"wpforms-43-field_5-state\" class=\"wpforms-field-sublabel after\">State<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-43-field_5-postal\" class=\"wpforms-field-address-postal wpforms-field-required wpforms-masked-input\" data-inputmask-mask=\"(99999)|(99999-9999)\" data-inputmask-keepstatic=\"true\" data-rule-inputmask-incomplete=\"1\" name=\"wpforms[fields][5][postal]\" aria-errormessage=\"wpforms-43-field_5-postal-error\" required><label for=\"wpforms-43-field_5-postal\" class=\"wpforms-field-sublabel after\">Zip Code<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-43-field_6-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"6\"><label class=\"wpforms-field-label\" for=\"wpforms-43-field_6\">Type of Pet <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-43-field_6\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][6]\" aria-errormessage=\"wpforms-43-field_6-error\" required><\/div><div id=\"wpforms-43-field_7-container\" class=\"wpforms-field wpforms-field-number\" data-field-type=\"number\" data-field-id=\"7\"><label class=\"wpforms-field-label\" for=\"wpforms-43-field_7\">Age of Pet <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"number\" id=\"wpforms-43-field_7\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][7]\" step=\"any\" aria-errormessage=\"wpforms-43-field_7-error\" required><\/div><div id=\"wpforms-43-field_8-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-type=\"date-time\" data-field-id=\"8\"><label class=\"wpforms-field-label\" for=\"wpforms-43-field_8\">Pet\u2019s Date of Birth <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-43-field_8\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][8][date]\" aria-errormessage=\"wpforms-43-field_8-error\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-43-field_9-container\" class=\"wpforms-field wpforms-field-radio\" data-field-type=\"radio\" data-field-id=\"9\"><fieldset><legend class=\"wpforms-field-label\">Pet Gender <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-43-field_9\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-43-field_9_1\" name=\"wpforms[fields][9]\" value=\"Male\" aria-errormessage=\"wpforms-43-field_9_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-43-field_9_1\">Male<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-43-field_9_2\" name=\"wpforms[fields][9]\" value=\"Female\" aria-errormessage=\"wpforms-43-field_9_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-43-field_9_2\">Female<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-43-field_10-container\" class=\"wpforms-field wpforms-field-radio\" data-field-type=\"radio\" data-field-id=\"10\"><fieldset><legend class=\"wpforms-field-label\">Spayed or Neutered <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-43-field_10\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-43-field_10_1\" name=\"wpforms[fields][10]\" value=\"Yes\" aria-errormessage=\"wpforms-43-field_10_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-43-field_10_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-43-field_10_2\" name=\"wpforms[fields][10]\" value=\"No\" aria-errormessage=\"wpforms-43-field_10_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-43-field_10_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-43-field_11-container\" class=\"wpforms-field wpforms-field-radio\" data-field-type=\"radio\" data-field-id=\"11\"><fieldset><legend class=\"wpforms-field-label\">Do You Have Pet Insurance <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-43-field_11\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-43-field_11_1\" name=\"wpforms[fields][11]\" value=\"Yes\" aria-errormessage=\"wpforms-43-field_11_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-43-field_11_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-43-field_11_2\" name=\"wpforms[fields][11]\" value=\"No\" aria-errormessage=\"wpforms-43-field_11_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-43-field_11_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-43-field_12-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"12\"><label class=\"wpforms-field-label\" for=\"wpforms-43-field_12\">Pet\u2019s breed <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-43-field_12\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][12]\" aria-errormessage=\"wpforms-43-field_12-error\" required><\/div><div id=\"wpforms-43-field_13-container\" class=\"wpforms-field wpforms-field-number\" data-field-type=\"number\" data-field-id=\"13\"><label class=\"wpforms-field-label\" for=\"wpforms-43-field_13\">Pet\u2019s weight <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"number\" id=\"wpforms-43-field_13\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][13]\" step=\"any\" aria-errormessage=\"wpforms-43-field_13-error\" required><\/div><div id=\"wpforms-43-field_14-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-43-field_14\">Referring Veterinary Practice <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-43-field_14\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][14]\" aria-errormessage=\"wpforms-43-field_14-error\" required><\/div><div id=\"wpforms-43-field_15-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"15\"><label class=\"wpforms-field-label\" for=\"wpforms-43-field_15\">Referring RDVM <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-43-field_15\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][15]\" aria-errormessage=\"wpforms-43-field_15-error\" required><\/div><div id=\"wpforms-43-field_16-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-type=\"textarea\" data-field-id=\"16\"><label class=\"wpforms-field-label\" for=\"wpforms-43-field_16\">Describe the medical condition your pet is currently suffering from. Please note if this is a chronic or acute condition and when it started. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-43-field_16\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][16]\" aria-errormessage=\"wpforms-43-field_16-error\" required><\/textarea><\/div><div id=\"wpforms-43-field_17-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-type=\"textarea\" data-field-id=\"17\"><label class=\"wpforms-field-label\" for=\"wpforms-43-field_17\">Describe the treatment plan for your pet. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-43-field_17\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][17]\" aria-errormessage=\"wpforms-43-field_17-error\" required><\/textarea><\/div><div id=\"wpforms-43-field_18-container\" class=\"wpforms-field wpforms-field-number\" data-field-type=\"number\" data-field-id=\"18\"><label class=\"wpforms-field-label\" for=\"wpforms-43-field_18\">How much will this treatment cost <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"number\" id=\"wpforms-43-field_18\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][18]\" step=\"any\" aria-errormessage=\"wpforms-43-field_18-error\" required><\/div><div id=\"wpforms-43-field_19-container\" class=\"wpforms-field wpforms-field-number\" data-field-type=\"number\" data-field-id=\"19\"><label class=\"wpforms-field-label\" for=\"wpforms-43-field_19\">How much can you pay for this treatment before it becomes an extremely significant financial hardship <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"number\" id=\"wpforms-43-field_19\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][19]\" step=\"any\" aria-errormessage=\"wpforms-43-field_19-error\" required><\/div><div id=\"wpforms-43-field_20-container\" class=\"wpforms-field wpforms-field-radio\" data-field-type=\"radio\" data-field-id=\"20\"><fieldset><legend class=\"wpforms-field-label\">Have you discussed a payment plan with your veterinarian <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-43-field_20\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-43-field_20_1\" name=\"wpforms[fields][20]\" value=\"Yes, but it is still a hardship\" aria-errormessage=\"wpforms-43-field_20_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-43-field_20_1\">Yes, but it is still a hardship<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-43-field_20_2\" name=\"wpforms[fields][20]\" value=\"No\" aria-errormessage=\"wpforms-43-field_20_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-43-field_20_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-43-field_21-container\" class=\"wpforms-field wpforms-field-radio\" data-field-type=\"radio\" data-field-id=\"21\"><fieldset><legend class=\"wpforms-field-label\">Applying to Care Credit carecredit.com or 800-677-0718 is a requirement for eligibility. Have you applied for and received Care Credit <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-43-field_21\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-43-field_21_1\" name=\"wpforms[fields][21]\" value=\"Yes, approved\" aria-errormessage=\"wpforms-43-field_21_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-43-field_21_1\">Yes, approved<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-43-field_21_2\" name=\"wpforms[fields][21]\" value=\"Yes, denied\" aria-errormessage=\"wpforms-43-field_21_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-43-field_21_2\">Yes, denied<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-43-field_21_3\" name=\"wpforms[fields][21]\" value=\"Yes, but still a hardship\" aria-errormessage=\"wpforms-43-field_21_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-43-field_21_3\">Yes, but still a hardship<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-43-field_21_4\" name=\"wpforms[fields][21]\" value=\"No\" aria-errormessage=\"wpforms-43-field_21_4-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-43-field_21_4\">No<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-43-field_21_5\" name=\"wpforms[fields][21]\" value=\"Pending\" aria-errormessage=\"wpforms-43-field_21_5-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-43-field_21_5\">Pending<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-43-field_22-container\" class=\"wpforms-field wpforms-field-number\" data-field-type=\"number\" data-field-id=\"22\"><label class=\"wpforms-field-label\" for=\"wpforms-43-field_22\">How many people are in your household <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"number\" id=\"wpforms-43-field_22\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][22]\" step=\"any\" aria-errormessage=\"wpforms-43-field_22-error\" required><\/div><div id=\"wpforms-43-field_23-container\" class=\"wpforms-field wpforms-field-number\" data-field-type=\"number\" data-field-id=\"23\"><label class=\"wpforms-field-label\" for=\"wpforms-43-field_23\">Provide the estimated monthly income of all adult members of your household <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"number\" id=\"wpforms-43-field_23\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][23]\" step=\"any\" aria-errormessage=\"wpforms-43-field_23-error\" required><\/div><div id=\"wpforms-43-field_24-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-type=\"textarea\" data-field-id=\"24\"><label class=\"wpforms-field-label\" for=\"wpforms-43-field_24\">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 <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-43-field_24\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][24]\" aria-errormessage=\"wpforms-43-field_24-error\" required><\/textarea><\/div><div id=\"wpforms-43-field_25-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-type=\"textarea\" data-field-id=\"25\"><label class=\"wpforms-field-label\" for=\"wpforms-43-field_25\">Describe briefly how paying for this treatment is a significant financial hardship. Are you or anyone in your family disabled a veteran andor sick? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-43-field_25\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][25]\" aria-errormessage=\"wpforms-43-field_25-error\" required><\/textarea><\/div><div id=\"wpforms-43-field_27-container\" class=\"wpforms-field wpforms-field-file-upload\" data-field-type=\"file-upload\" data-field-id=\"27\"><label class=\"wpforms-field-label\" for=\"wpforms-43-field_27\">Pet Image <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div\n\t\tclass=\"wpforms-uploader wpforms-field-required\"\n\t\tdata-field-id=\"27\"\n\t\tdata-form-id=\"43\"\n\t\tdata-input-name=\"wpforms_43_27\"\n\t\tdata-extensions=\"jpg,jpeg,jpe,gif,png,bmp,tiff,tif,webp,avif,ico,heic,heif,heics,heifs,asf,asx,wmv,wmx,wm,avi,divx,mov,qt,mpeg,mpg,mpe,mp4,m4v,ogv,webm,mkv,3gp,3gpp,3g2,3gp2,txt,asc,c,cc,h,srt,csv,tsv,ics,rtx,css,vtt,mp3,m4a,m4b,aac,ra,ram,wav,x-wav,ogg,oga,flac,mid,midi,wma,wax,mka,rtf,pdf,class,tar,zip,gz,gzip,rar,7z,psd,xcf,doc,pot,pps,ppt,wri,xla,xls,xlt,xlw,mpp,docx,docm,dotx,dotm,xlsx,xlsm,xlsb,xltx,xltm,xlam,pptx,pptm,ppsx,ppsm,potx,potm,ppam,sldx,sldm,onetoc,onetoc2,onepkg,oxps,xps,odt,odp,ods,odg,odc,odb,odf,wp,wpd,key,numbers,pages\"\n\t\tdata-max-size=\"536870912\"\n\t\tdata-max-file-number=\"1\"\n\t\tdata-post-max-size=\"536870912\"\n\t\tdata-max-parallel-uploads=\"4\"\n\t\tdata-parallel-uploads=\"true\"\n\t\tdata-file-chunk-size=\"2097152\">\n\t<div class=\"dz-message\">\n\t\t<svg  viewBox=\"0 0 640 640\" focusable=\"false\" data-icon=\"inbox\" width=\"50px\" height=\"50px\" fill=\"currentColor\" aria-hidden=\"true\">\n\t\t\t<path d=\"M352 173.3L352 384C352 401.7 337.7 416 320 416C302.3 416 288 401.7 288 384L288 173.3L246.6 214.7C234.1 227.2 213.8 227.2 201.3 214.7C188.8 202.2 188.8 181.9 201.3 169.4L297.3 73.4C309.8 60.9 330.1 60.9 342.6 73.4L438.6 169.4C451.1 181.9 451.1 202.2 438.6 214.7C426.1 227.2 405.8 227.2 393.3 214.7L352 173.3zM320 464C364.2 464 400 428.2 400 384L480 384C515.3 384 544 412.7 544 448L544 480C544 515.3 515.3 544 480 544L160 544C124.7 544 96 515.3 96 480L96 448C96 412.7 124.7 384 160 384L240 384C240 428.2 275.8 464 320 464zM464 488C477.3 488 488 477.3 488 464C488 450.7 477.3 440 464 440C450.7 440 440 450.7 440 464C440 477.3 450.7 488 464 488z\"\/>\n\t\t<\/svg>\n\n\t\t<span class=\"modern-title\">\n\t\t\t\t\t\t\tDrag &amp; Drop Files, \t\t\t\t<span>Choose Files to Upload<\/span>\n\t\t\t\t\t<\/span>\n\n\t\t\t<\/div>\n<\/div>\n\n<input\n\t\ttype=\"text\"\n\t\tautocomplete=\"off\"\n\t\treadonly\n\t\tclass=\"dropzone-input\"\n\t\tstyle=\"position:absolute!important;clip:rect(0,0,0,0)!important;height:1px!important;width:1px!important;border:0!important;overflow:hidden!important;padding:0!important;margin:0!important;\"\n\t\tid=\"wpforms-43-field_27\"\n\t\tname=\"wpforms_43_27\" required\t\tvalue=\"\">\n<\/div><div id=\"wpforms-43-field_28-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-type=\"radio\" data-field-id=\"28\"><fieldset><legend class=\"wpforms-field-label\">Do you file income taxes <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-43-field_28\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-43-field_28_1\" name=\"wpforms[fields][28]\" value=\"Yes\" aria-errormessage=\"wpforms-43-field_28_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-43-field_28_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-43-field_28_2\" name=\"wpforms[fields][28]\" value=\"No\" aria-errormessage=\"wpforms-43-field_28_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-43-field_28_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-43-field_29-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-type=\"textarea\" data-field-id=\"29\"><label class=\"wpforms-field-label\" for=\"wpforms-43-field_29\">If no why have you chosen to not file taxes <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-43-field_29\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][29]\" aria-errormessage=\"wpforms-43-field_29-error\" required><\/textarea><\/div><div id=\"wpforms-43-field_30-container\" class=\"wpforms-field wpforms-field-file-upload wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"file-upload\" data-field-id=\"30\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-43-field_30\">Please upload the first and last pages of your most recent income tax return. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div\n\t\tclass=\"wpforms-uploader wpforms-field-required\"\n\t\tdata-field-id=\"30\"\n\t\tdata-form-id=\"43\"\n\t\tdata-input-name=\"wpforms_43_30\"\n\t\tdata-extensions=\"jpg,jpeg,jpe,gif,png,bmp,tiff,tif,webp,avif,ico,heic,heif,heics,heifs,asf,asx,wmv,wmx,wm,avi,divx,mov,qt,mpeg,mpg,mpe,mp4,m4v,ogv,webm,mkv,3gp,3gpp,3g2,3gp2,txt,asc,c,cc,h,srt,csv,tsv,ics,rtx,css,vtt,mp3,m4a,m4b,aac,ra,ram,wav,x-wav,ogg,oga,flac,mid,midi,wma,wax,mka,rtf,pdf,class,tar,zip,gz,gzip,rar,7z,psd,xcf,doc,pot,pps,ppt,wri,xla,xls,xlt,xlw,mpp,docx,docm,dotx,dotm,xlsx,xlsm,xlsb,xltx,xltm,xlam,pptx,pptm,ppsx,ppsm,potx,potm,ppam,sldx,sldm,onetoc,onetoc2,onepkg,oxps,xps,odt,odp,ods,odg,odc,odb,odf,wp,wpd,key,numbers,pages\"\n\t\tdata-max-size=\"536870912\"\n\t\tdata-max-file-number=\"1\"\n\t\tdata-post-max-size=\"536870912\"\n\t\tdata-max-parallel-uploads=\"4\"\n\t\tdata-parallel-uploads=\"true\"\n\t\tdata-file-chunk-size=\"2097152\">\n\t<div class=\"dz-message\">\n\t\t<svg  viewBox=\"0 0 640 640\" focusable=\"false\" data-icon=\"inbox\" width=\"50px\" height=\"50px\" fill=\"currentColor\" aria-hidden=\"true\">\n\t\t\t<path d=\"M352 173.3L352 384C352 401.7 337.7 416 320 416C302.3 416 288 401.7 288 384L288 173.3L246.6 214.7C234.1 227.2 213.8 227.2 201.3 214.7C188.8 202.2 188.8 181.9 201.3 169.4L297.3 73.4C309.8 60.9 330.1 60.9 342.6 73.4L438.6 169.4C451.1 181.9 451.1 202.2 438.6 214.7C426.1 227.2 405.8 227.2 393.3 214.7L352 173.3zM320 464C364.2 464 400 428.2 400 384L480 384C515.3 384 544 412.7 544 448L544 480C544 515.3 515.3 544 480 544L160 544C124.7 544 96 515.3 96 480L96 448C96 412.7 124.7 384 160 384L240 384C240 428.2 275.8 464 320 464zM464 488C477.3 488 488 477.3 488 464C488 450.7 477.3 440 464 440C450.7 440 440 450.7 440 464C440 477.3 450.7 488 464 488z\"\/>\n\t\t<\/svg>\n\n\t\t<span class=\"modern-title\">\n\t\t\t\t\t\t\tDrag &amp; Drop Files, \t\t\t\t<span>Choose Files to Upload<\/span>\n\t\t\t\t\t<\/span>\n\n\t\t\t<\/div>\n<\/div>\n\n<input\n\t\ttype=\"text\"\n\t\tautocomplete=\"off\"\n\t\treadonly\n\t\tclass=\"dropzone-input\"\n\t\tstyle=\"position:absolute!important;clip:rect(0,0,0,0)!important;height:1px!important;width:1px!important;border:0!important;overflow:hidden!important;padding:0!important;margin:0!important;\"\n\t\tid=\"wpforms-43-field_30\"\n\t\tname=\"wpforms_43_30\" required\t\tvalue=\"\">\n<\/div><div id=\"wpforms-43-field_31-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-type=\"radio\" data-field-id=\"31\"><fieldset><legend class=\"wpforms-field-label\">Did you apply for a Care Credit loan This is required. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-43-field_31\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-43-field_31_1\" name=\"wpforms[fields][31]\" value=\"Yes\" aria-errormessage=\"wpforms-43-field_31_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-43-field_31_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-43-field_31_2\" name=\"wpforms[fields][31]\" value=\"No\" aria-errormessage=\"wpforms-43-field_31_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-43-field_31_2\">No<\/label><\/li><\/ul><\/fieldset><\/div>\t\t<div id=\"wpforms-43-field_26-container\"\n\t\t\tclass=\"wpforms-field wpforms-field-text\"\n\t\t\tdata-field-type=\"text\"\n\t\t\tdata-field-id=\"26\"\n\t\t\t>\n\t\t\t<label class=\"wpforms-field-label\" for=\"wpforms-43-field_26\" >monthly you property<\/label>\n\t\t\t<input type=\"text\" id=\"wpforms-43-field_26\" class=\"wpforms-field-medium\" name=\"wpforms[fields][26]\" >\n\t\t<\/div>\n\t\t<div id=\"wpforms-43-field_32-container\" class=\"wpforms-field wpforms-field-file-upload wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"file-upload\" data-field-id=\"32\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-43-field_32\">Please upload your proof of Care Credit denial or loan amount. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div\n\t\tclass=\"wpforms-uploader wpforms-field-required\"\n\t\tdata-field-id=\"32\"\n\t\tdata-form-id=\"43\"\n\t\tdata-input-name=\"wpforms_43_32\"\n\t\tdata-extensions=\"jpg,jpeg,jpe,gif,png,bmp,tiff,tif,webp,avif,ico,heic,heif,heics,heifs,asf,asx,wmv,wmx,wm,avi,divx,mov,qt,mpeg,mpg,mpe,mp4,m4v,ogv,webm,mkv,3gp,3gpp,3g2,3gp2,txt,asc,c,cc,h,srt,csv,tsv,ics,rtx,css,vtt,mp3,m4a,m4b,aac,ra,ram,wav,x-wav,ogg,oga,flac,mid,midi,wma,wax,mka,rtf,pdf,class,tar,zip,gz,gzip,rar,7z,psd,xcf,doc,pot,pps,ppt,wri,xla,xls,xlt,xlw,mpp,docx,docm,dotx,dotm,xlsx,xlsm,xlsb,xltx,xltm,xlam,pptx,pptm,ppsx,ppsm,potx,potm,ppam,sldx,sldm,onetoc,onetoc2,onepkg,oxps,xps,odt,odp,ods,odg,odc,odb,odf,wp,wpd,key,numbers,pages\"\n\t\tdata-max-size=\"536870912\"\n\t\tdata-max-file-number=\"1\"\n\t\tdata-post-max-size=\"536870912\"\n\t\tdata-max-parallel-uploads=\"4\"\n\t\tdata-parallel-uploads=\"true\"\n\t\tdata-file-chunk-size=\"2097152\">\n\t<div class=\"dz-message\">\n\t\t<svg  viewBox=\"0 0 640 640\" focusable=\"false\" data-icon=\"inbox\" width=\"50px\" height=\"50px\" fill=\"currentColor\" aria-hidden=\"true\">\n\t\t\t<path d=\"M352 173.3L352 384C352 401.7 337.7 416 320 416C302.3 416 288 401.7 288 384L288 173.3L246.6 214.7C234.1 227.2 213.8 227.2 201.3 214.7C188.8 202.2 188.8 181.9 201.3 169.4L297.3 73.4C309.8 60.9 330.1 60.9 342.6 73.4L438.6 169.4C451.1 181.9 451.1 202.2 438.6 214.7C426.1 227.2 405.8 227.2 393.3 214.7L352 173.3zM320 464C364.2 464 400 428.2 400 384L480 384C515.3 384 544 412.7 544 448L544 480C544 515.3 515.3 544 480 544L160 544C124.7 544 96 515.3 96 480L96 448C96 412.7 124.7 384 160 384L240 384C240 428.2 275.8 464 320 464zM464 488C477.3 488 488 477.3 488 464C488 450.7 477.3 440 464 440C450.7 440 440 450.7 440 464C440 477.3 450.7 488 464 488z\"\/>\n\t\t<\/svg>\n\n\t\t<span class=\"modern-title\">\n\t\t\t\t\t\t\tDrag &amp; Drop Files, \t\t\t\t<span>Choose Files to Upload<\/span>\n\t\t\t\t\t<\/span>\n\n\t\t\t<\/div>\n<\/div>\n\n<input\n\t\ttype=\"text\"\n\t\tautocomplete=\"off\"\n\t\treadonly\n\t\tclass=\"dropzone-input\"\n\t\tstyle=\"position:absolute!important;clip:rect(0,0,0,0)!important;height:1px!important;width:1px!important;border:0!important;overflow:hidden!important;padding:0!important;margin:0!important;\"\n\t\tid=\"wpforms-43-field_32\"\n\t\tname=\"wpforms_43_32\" required\t\tvalue=\"\">\n<\/div><div id=\"wpforms-43-field_33-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-type=\"radio\" data-field-id=\"33\"><fieldset><legend class=\"wpforms-field-label\">Did you apply for a Scratch Pay loan <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-43-field_33\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-43-field_33_1\" name=\"wpforms[fields][33]\" value=\"Yes\" aria-errormessage=\"wpforms-43-field_33_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-43-field_33_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-43-field_33_2\" name=\"wpforms[fields][33]\" value=\"No\" aria-errormessage=\"wpforms-43-field_33_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-43-field_33_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-43-field_34-container\" class=\"wpforms-field wpforms-field-file-upload wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"file-upload\" data-field-id=\"34\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-43-field_34\">Please upload your proof of Scratch Pay denial or loan amount. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div\n\t\tclass=\"wpforms-uploader wpforms-field-required\"\n\t\tdata-field-id=\"34\"\n\t\tdata-form-id=\"43\"\n\t\tdata-input-name=\"wpforms_43_34\"\n\t\tdata-extensions=\"jpg,jpeg,jpe,gif,png,bmp,tiff,tif,webp,avif,ico,heic,heif,heics,heifs,asf,asx,wmv,wmx,wm,avi,divx,mov,qt,mpeg,mpg,mpe,mp4,m4v,ogv,webm,mkv,3gp,3gpp,3g2,3gp2,txt,asc,c,cc,h,srt,csv,tsv,ics,rtx,css,vtt,mp3,m4a,m4b,aac,ra,ram,wav,x-wav,ogg,oga,flac,mid,midi,wma,wax,mka,rtf,pdf,class,tar,zip,gz,gzip,rar,7z,psd,xcf,doc,pot,pps,ppt,wri,xla,xls,xlt,xlw,mpp,docx,docm,dotx,dotm,xlsx,xlsm,xlsb,xltx,xltm,xlam,pptx,pptm,ppsx,ppsm,potx,potm,ppam,sldx,sldm,onetoc,onetoc2,onepkg,oxps,xps,odt,odp,ods,odg,odc,odb,odf,wp,wpd,key,numbers,pages\"\n\t\tdata-max-size=\"536870912\"\n\t\tdata-max-file-number=\"1\"\n\t\tdata-post-max-size=\"536870912\"\n\t\tdata-max-parallel-uploads=\"4\"\n\t\tdata-parallel-uploads=\"true\"\n\t\tdata-file-chunk-size=\"2097152\">\n\t<div class=\"dz-message\">\n\t\t<svg  viewBox=\"0 0 640 640\" focusable=\"false\" data-icon=\"inbox\" width=\"50px\" height=\"50px\" fill=\"currentColor\" aria-hidden=\"true\">\n\t\t\t<path d=\"M352 173.3L352 384C352 401.7 337.7 416 320 416C302.3 416 288 401.7 288 384L288 173.3L246.6 214.7C234.1 227.2 213.8 227.2 201.3 214.7C188.8 202.2 188.8 181.9 201.3 169.4L297.3 73.4C309.8 60.9 330.1 60.9 342.6 73.4L438.6 169.4C451.1 181.9 451.1 202.2 438.6 214.7C426.1 227.2 405.8 227.2 393.3 214.7L352 173.3zM320 464C364.2 464 400 428.2 400 384L480 384C515.3 384 544 412.7 544 448L544 480C544 515.3 515.3 544 480 544L160 544C124.7 544 96 515.3 96 480L96 448C96 412.7 124.7 384 160 384L240 384C240 428.2 275.8 464 320 464zM464 488C477.3 488 488 477.3 488 464C488 450.7 477.3 440 464 440C450.7 440 440 450.7 440 464C440 477.3 450.7 488 464 488z\"\/>\n\t\t<\/svg>\n\n\t\t<span class=\"modern-title\">\n\t\t\t\t\t\t\tDrag &amp; Drop Files, \t\t\t\t<span>Choose Files to Upload<\/span>\n\t\t\t\t\t<\/span>\n\n\t\t\t<\/div>\n<\/div>\n\n<input\n\t\ttype=\"text\"\n\t\tautocomplete=\"off\"\n\t\treadonly\n\t\tclass=\"dropzone-input\"\n\t\tstyle=\"position:absolute!important;clip:rect(0,0,0,0)!important;height:1px!important;width:1px!important;border:0!important;overflow:hidden!important;padding:0!important;margin:0!important;\"\n\t\tid=\"wpforms-43-field_34\"\n\t\tname=\"wpforms_43_34\" required\t\tvalue=\"\">\n<\/div><div id=\"wpforms-43-field_35-container\" class=\"wpforms-field wpforms-field-file-upload\" data-field-type=\"file-upload\" data-field-id=\"35\"><label class=\"wpforms-field-label\" for=\"wpforms-43-field_35\">Please provide proof of monthly inocme. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div\n\t\tclass=\"wpforms-uploader wpforms-field-required\"\n\t\tdata-field-id=\"35\"\n\t\tdata-form-id=\"43\"\n\t\tdata-input-name=\"wpforms_43_35\"\n\t\tdata-extensions=\"jpg,jpeg,jpe,gif,png,bmp,tiff,tif,webp,avif,ico,heic,heif,heics,heifs,asf,asx,wmv,wmx,wm,avi,divx,mov,qt,mpeg,mpg,mpe,mp4,m4v,ogv,webm,mkv,3gp,3gpp,3g2,3gp2,txt,asc,c,cc,h,srt,csv,tsv,ics,rtx,css,vtt,mp3,m4a,m4b,aac,ra,ram,wav,x-wav,ogg,oga,flac,mid,midi,wma,wax,mka,rtf,pdf,class,tar,zip,gz,gzip,rar,7z,psd,xcf,doc,pot,pps,ppt,wri,xla,xls,xlt,xlw,mpp,docx,docm,dotx,dotm,xlsx,xlsm,xlsb,xltx,xltm,xlam,pptx,pptm,ppsx,ppsm,potx,potm,ppam,sldx,sldm,onetoc,onetoc2,onepkg,oxps,xps,odt,odp,ods,odg,odc,odb,odf,wp,wpd,key,numbers,pages\"\n\t\tdata-max-size=\"536870912\"\n\t\tdata-max-file-number=\"1\"\n\t\tdata-post-max-size=\"536870912\"\n\t\tdata-max-parallel-uploads=\"4\"\n\t\tdata-parallel-uploads=\"true\"\n\t\tdata-file-chunk-size=\"2097152\">\n\t<div class=\"dz-message\">\n\t\t<svg  viewBox=\"0 0 640 640\" focusable=\"false\" data-icon=\"inbox\" width=\"50px\" height=\"50px\" fill=\"currentColor\" aria-hidden=\"true\">\n\t\t\t<path d=\"M352 173.3L352 384C352 401.7 337.7 416 320 416C302.3 416 288 401.7 288 384L288 173.3L246.6 214.7C234.1 227.2 213.8 227.2 201.3 214.7C188.8 202.2 188.8 181.9 201.3 169.4L297.3 73.4C309.8 60.9 330.1 60.9 342.6 73.4L438.6 169.4C451.1 181.9 451.1 202.2 438.6 214.7C426.1 227.2 405.8 227.2 393.3 214.7L352 173.3zM320 464C364.2 464 400 428.2 400 384L480 384C515.3 384 544 412.7 544 448L544 480C544 515.3 515.3 544 480 544L160 544C124.7 544 96 515.3 96 480L96 448C96 412.7 124.7 384 160 384L240 384C240 428.2 275.8 464 320 464zM464 488C477.3 488 488 477.3 488 464C488 450.7 477.3 440 464 440C450.7 440 440 450.7 440 464C440 477.3 450.7 488 464 488z\"\/>\n\t\t<\/svg>\n\n\t\t<span class=\"modern-title\">\n\t\t\t\t\t\t\tDrag &amp; Drop Files, \t\t\t\t<span>Choose Files to Upload<\/span>\n\t\t\t\t\t<\/span>\n\n\t\t\t<\/div>\n<\/div>\n\n<input\n\t\ttype=\"text\"\n\t\tautocomplete=\"off\"\n\t\treadonly\n\t\tclass=\"dropzone-input\"\n\t\tstyle=\"position:absolute!important;clip:rect(0,0,0,0)!important;height:1px!important;width:1px!important;border:0!important;overflow:hidden!important;padding:0!important;margin:0!important;\"\n\t\tid=\"wpforms-43-field_35\"\n\t\tname=\"wpforms_43_35\" required\t\tvalue=\"\">\n<\/div><div id=\"wpforms-43-field_36-container\" class=\"wpforms-field wpforms-field-file-upload\" data-field-type=\"file-upload\" data-field-id=\"36\"><label class=\"wpforms-field-label\" for=\"wpforms-43-field_36\">Please provide proof of monthly income if employed for all members of your household. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div\n\t\tclass=\"wpforms-uploader wpforms-field-required\"\n\t\tdata-field-id=\"36\"\n\t\tdata-form-id=\"43\"\n\t\tdata-input-name=\"wpforms_43_36\"\n\t\tdata-extensions=\"jpg,jpeg,jpe,gif,png,bmp,tiff,tif,webp,avif,ico,heic,heif,heics,heifs,asf,asx,wmv,wmx,wm,avi,divx,mov,qt,mpeg,mpg,mpe,mp4,m4v,ogv,webm,mkv,3gp,3gpp,3g2,3gp2,txt,asc,c,cc,h,srt,csv,tsv,ics,rtx,css,vtt,mp3,m4a,m4b,aac,ra,ram,wav,x-wav,ogg,oga,flac,mid,midi,wma,wax,mka,rtf,pdf,class,tar,zip,gz,gzip,rar,7z,psd,xcf,doc,pot,pps,ppt,wri,xla,xls,xlt,xlw,mpp,docx,docm,dotx,dotm,xlsx,xlsm,xlsb,xltx,xltm,xlam,pptx,pptm,ppsx,ppsm,potx,potm,ppam,sldx,sldm,onetoc,onetoc2,onepkg,oxps,xps,odt,odp,ods,odg,odc,odb,odf,wp,wpd,key,numbers,pages\"\n\t\tdata-max-size=\"536870912\"\n\t\tdata-max-file-number=\"1\"\n\t\tdata-post-max-size=\"536870912\"\n\t\tdata-max-parallel-uploads=\"4\"\n\t\tdata-parallel-uploads=\"true\"\n\t\tdata-file-chunk-size=\"2097152\">\n\t<div class=\"dz-message\">\n\t\t<svg  viewBox=\"0 0 640 640\" focusable=\"false\" data-icon=\"inbox\" width=\"50px\" height=\"50px\" fill=\"currentColor\" aria-hidden=\"true\">\n\t\t\t<path d=\"M352 173.3L352 384C352 401.7 337.7 416 320 416C302.3 416 288 401.7 288 384L288 173.3L246.6 214.7C234.1 227.2 213.8 227.2 201.3 214.7C188.8 202.2 188.8 181.9 201.3 169.4L297.3 73.4C309.8 60.9 330.1 60.9 342.6 73.4L438.6 169.4C451.1 181.9 451.1 202.2 438.6 214.7C426.1 227.2 405.8 227.2 393.3 214.7L352 173.3zM320 464C364.2 464 400 428.2 400 384L480 384C515.3 384 544 412.7 544 448L544 480C544 515.3 515.3 544 480 544L160 544C124.7 544 96 515.3 96 480L96 448C96 412.7 124.7 384 160 384L240 384C240 428.2 275.8 464 320 464zM464 488C477.3 488 488 477.3 488 464C488 450.7 477.3 440 464 440C450.7 440 440 450.7 440 464C440 477.3 450.7 488 464 488z\"\/>\n\t\t<\/svg>\n\n\t\t<span class=\"modern-title\">\n\t\t\t\t\t\t\tDrag &amp; Drop Files, \t\t\t\t<span>Choose Files to Upload<\/span>\n\t\t\t\t\t<\/span>\n\n\t\t\t<\/div>\n<\/div>\n\n<input\n\t\ttype=\"text\"\n\t\tautocomplete=\"off\"\n\t\treadonly\n\t\tclass=\"dropzone-input\"\n\t\tstyle=\"position:absolute!important;clip:rect(0,0,0,0)!important;height:1px!important;width:1px!important;border:0!important;overflow:hidden!important;padding:0!important;margin:0!important;\"\n\t\tid=\"wpforms-43-field_36\"\n\t\tname=\"wpforms_43_36\" required\t\tvalue=\"\">\n<\/div><div id=\"wpforms-43-field_37-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-type=\"radio\" data-field-id=\"37\"><fieldset><legend class=\"wpforms-field-label\">Are you on government assistance <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-43-field_37\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-43-field_37_1\" name=\"wpforms[fields][37]\" value=\"Yes\" aria-errormessage=\"wpforms-43-field_37_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-43-field_37_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-43-field_37_2\" name=\"wpforms[fields][37]\" value=\"No\" aria-errormessage=\"wpforms-43-field_37_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-43-field_37_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-43-field_38-container\" class=\"wpforms-field wpforms-field-file-upload wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"file-upload\" data-field-id=\"38\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-43-field_38\">Please provide proof of government assistance with the monthly income. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div\n\t\tclass=\"wpforms-uploader wpforms-field-required\"\n\t\tdata-field-id=\"38\"\n\t\tdata-form-id=\"43\"\n\t\tdata-input-name=\"wpforms_43_38\"\n\t\tdata-extensions=\"jpg,jpeg,jpe,gif,png,bmp,tiff,tif,webp,avif,ico,heic,heif,heics,heifs,asf,asx,wmv,wmx,wm,avi,divx,mov,qt,mpeg,mpg,mpe,mp4,m4v,ogv,webm,mkv,3gp,3gpp,3g2,3gp2,txt,asc,c,cc,h,srt,csv,tsv,ics,rtx,css,vtt,mp3,m4a,m4b,aac,ra,ram,wav,x-wav,ogg,oga,flac,mid,midi,wma,wax,mka,rtf,pdf,class,tar,zip,gz,gzip,rar,7z,psd,xcf,doc,pot,pps,ppt,wri,xla,xls,xlt,xlw,mpp,docx,docm,dotx,dotm,xlsx,xlsm,xlsb,xltx,xltm,xlam,pptx,pptm,ppsx,ppsm,potx,potm,ppam,sldx,sldm,onetoc,onetoc2,onepkg,oxps,xps,odt,odp,ods,odg,odc,odb,odf,wp,wpd,key,numbers,pages\"\n\t\tdata-max-size=\"536870912\"\n\t\tdata-max-file-number=\"1\"\n\t\tdata-post-max-size=\"536870912\"\n\t\tdata-max-parallel-uploads=\"4\"\n\t\tdata-parallel-uploads=\"true\"\n\t\tdata-file-chunk-size=\"2097152\">\n\t<div class=\"dz-message\">\n\t\t<svg  viewBox=\"0 0 640 640\" focusable=\"false\" data-icon=\"inbox\" width=\"50px\" height=\"50px\" fill=\"currentColor\" aria-hidden=\"true\">\n\t\t\t<path d=\"M352 173.3L352 384C352 401.7 337.7 416 320 416C302.3 416 288 401.7 288 384L288 173.3L246.6 214.7C234.1 227.2 213.8 227.2 201.3 214.7C188.8 202.2 188.8 181.9 201.3 169.4L297.3 73.4C309.8 60.9 330.1 60.9 342.6 73.4L438.6 169.4C451.1 181.9 451.1 202.2 438.6 214.7C426.1 227.2 405.8 227.2 393.3 214.7L352 173.3zM320 464C364.2 464 400 428.2 400 384L480 384C515.3 384 544 412.7 544 448L544 480C544 515.3 515.3 544 480 544L160 544C124.7 544 96 515.3 96 480L96 448C96 412.7 124.7 384 160 384L240 384C240 428.2 275.8 464 320 464zM464 488C477.3 488 488 477.3 488 464C488 450.7 477.3 440 464 440C450.7 440 440 450.7 440 464C440 477.3 450.7 488 464 488z\"\/>\n\t\t<\/svg>\n\n\t\t<span class=\"modern-title\">\n\t\t\t\t\t\t\tDrag &amp; Drop Files, \t\t\t\t<span>Choose Files to Upload<\/span>\n\t\t\t\t\t<\/span>\n\n\t\t\t<\/div>\n<\/div>\n\n<input\n\t\ttype=\"text\"\n\t\tautocomplete=\"off\"\n\t\treadonly\n\t\tclass=\"dropzone-input\"\n\t\tstyle=\"position:absolute!important;clip:rect(0,0,0,0)!important;height:1px!important;width:1px!important;border:0!important;overflow:hidden!important;padding:0!important;margin:0!important;\"\n\t\tid=\"wpforms-43-field_38\"\n\t\tname=\"wpforms_43_38\" required\t\tvalue=\"\">\n<\/div><div id=\"wpforms-43-field_42-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-type=\"checkbox\" data-field-id=\"42\"><fieldset><legend class=\"wpforms-field-label\">I grant Guardian Heals the future right to use my pet&#039;s name, image, and story in promotional materials. I understand that I will be contacted again to confirm if GH chooses to do so. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-43-field_42\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-43-field_42_1\" name=\"wpforms[fields][42][]\" value=\"Permission\" aria-errormessage=\"wpforms-43-field_42_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-43-field_42_1\">Permission<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-43-field_43-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-type=\"date-time\" data-field-id=\"43\"><label class=\"wpforms-field-label\" for=\"wpforms-43-field_43\">Date  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-43-field_43\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][43][date]\" aria-errormessage=\"wpforms-43-field_43-error\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><script>\n\t\t\t\t( function() {\n\t\t\t\t\tconst style = document.createElement( 'style' );\n\t\t\t\t\tstyle.appendChild( document.createTextNode( '#wpforms-43-field_26-container { position: absolute !important; overflow: hidden !important; display: inline !important; height: 1px !important; width: 1px !important; z-index: -1000 !important; padding: 0 !important; } #wpforms-43-field_26-container input { visibility: hidden; } #wpforms-conversational-form-page #wpforms-43-field_26-container label { counter-increment: none; }' ) );\n\t\t\t\t\tdocument.head.appendChild( style );\n\t\t\t\t\tdocument.currentScript?.remove();\n\t\t\t\t} )();\n\t\t\t<\/script><\/div><!-- .wpforms-field-container --><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"43\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/healspets.org\/index.php?rest_route=\/wp\/v2\/pages\/85\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-43\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><\/div><\/form><\/div>  <!-- .wpforms-container -->\n\n\n<div class=\"wp-block-group alignfull is-layout-flow wp-container-core-group-is-layout-f9cb6abc wp-block-group-is-layout-flow\" style=\"margin-top:0;margin-bottom:0\">\n<div class=\"wp-block-columns alignfull is-style-section-2 is-layout-flex wp-container-core-columns-is-layout-d9884270 wp-block-columns-is-layout-flex is-style-section-2--1\" style=\"padding-top:0;padding-bottom:0\"><\/div>\n<\/div>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-85","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.3 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Application For Financial Assistance - HealsPets<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/healspets.org\/?page_id=85\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Application For Financial Assistance - HealsPets\" \/>\n<meta property=\"og:url\" content=\"https:\/\/healspets.org\/?page_id=85\" \/>\n<meta property=\"og:site_name\" content=\"HealsPets\" \/>\n<meta property=\"article:modified_time\" content=\"2026-02-16T13:19:41+00:00\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\\\/\\\/schema.org\",\"@graph\":[{\"@type\":\"WebPage\",\"@id\":\"https:\\\/\\\/healspets.org\\\/?page_id=85\",\"url\":\"https:\\\/\\\/healspets.org\\\/?page_id=85\",\"name\":\"Application For Financial Assistance - HealsPets\",\"isPartOf\":{\"@id\":\"https:\\\/\\\/healspets.org\\\/#website\"},\"datePublished\":\"2026-02-16T13:16:45+00:00\",\"dateModified\":\"2026-02-16T13:19:41+00:00\",\"breadcrumb\":{\"@id\":\"https:\\\/\\\/healspets.org\\\/?page_id=85#breadcrumb\"},\"inLanguage\":\"en-US\",\"potentialAction\":[{\"@type\":\"ReadAction\",\"target\":[\"https:\\\/\\\/healspets.org\\\/?page_id=85\"]}]},{\"@type\":\"BreadcrumbList\",\"@id\":\"https:\\\/\\\/healspets.org\\\/?page_id=85#breadcrumb\",\"itemListElement\":[{\"@type\":\"ListItem\",\"position\":1,\"name\":\"Home\",\"item\":\"https:\\\/\\\/healspets.org\\\/\"},{\"@type\":\"ListItem\",\"position\":2,\"name\":\"Application For Financial Assistance\"}]},{\"@type\":\"WebSite\",\"@id\":\"https:\\\/\\\/healspets.org\\\/#website\",\"url\":\"https:\\\/\\\/healspets.org\\\/\",\"name\":\"HealsPets\",\"description\":\"\",\"potentialAction\":[{\"@type\":\"SearchAction\",\"target\":{\"@type\":\"EntryPoint\",\"urlTemplate\":\"https:\\\/\\\/healspets.org\\\/?s={search_term_string}\"},\"query-input\":{\"@type\":\"PropertyValueSpecification\",\"valueRequired\":true,\"valueName\":\"search_term_string\"}}],\"inLanguage\":\"en-US\"}]}<\/script>\n<!-- \/ Yoast SEO plugin. -->","yoast_head_json":{"title":"Application For Financial Assistance - HealsPets","robots":{"index":"index","follow":"follow","max-snippet":"max-snippet:-1","max-image-preview":"max-image-preview:large","max-video-preview":"max-video-preview:-1"},"canonical":"https:\/\/healspets.org\/?page_id=85","og_locale":"en_US","og_type":"article","og_title":"Application For Financial Assistance - HealsPets","og_url":"https:\/\/healspets.org\/?page_id=85","og_site_name":"HealsPets","article_modified_time":"2026-02-16T13:19:41+00:00","twitter_card":"summary_large_image","schema":{"@context":"https:\/\/schema.org","@graph":[{"@type":"WebPage","@id":"https:\/\/healspets.org\/?page_id=85","url":"https:\/\/healspets.org\/?page_id=85","name":"Application For Financial Assistance - HealsPets","isPartOf":{"@id":"https:\/\/healspets.org\/#website"},"datePublished":"2026-02-16T13:16:45+00:00","dateModified":"2026-02-16T13:19:41+00:00","breadcrumb":{"@id":"https:\/\/healspets.org\/?page_id=85#breadcrumb"},"inLanguage":"en-US","potentialAction":[{"@type":"ReadAction","target":["https:\/\/healspets.org\/?page_id=85"]}]},{"@type":"BreadcrumbList","@id":"https:\/\/healspets.org\/?page_id=85#breadcrumb","itemListElement":[{"@type":"ListItem","position":1,"name":"Home","item":"https:\/\/healspets.org\/"},{"@type":"ListItem","position":2,"name":"Application For Financial Assistance"}]},{"@type":"WebSite","@id":"https:\/\/healspets.org\/#website","url":"https:\/\/healspets.org\/","name":"HealsPets","description":"","potentialAction":[{"@type":"SearchAction","target":{"@type":"EntryPoint","urlTemplate":"https:\/\/healspets.org\/?s={search_term_string}"},"query-input":{"@type":"PropertyValueSpecification","valueRequired":true,"valueName":"search_term_string"}}],"inLanguage":"en-US"}]}},"brizy_media":[],"_links":{"self":[{"href":"https:\/\/healspets.org\/index.php?rest_route=\/wp\/v2\/pages\/85","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/healspets.org\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/healspets.org\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/healspets.org\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/healspets.org\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=85"}],"version-history":[{"count":2,"href":"https:\/\/healspets.org\/index.php?rest_route=\/wp\/v2\/pages\/85\/revisions"}],"predecessor-version":[{"id":87,"href":"https:\/\/healspets.org\/index.php?rest_route=\/wp\/v2\/pages\/85\/revisions\/87"}],"wp:attachment":[{"href":"https:\/\/healspets.org\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=85"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}