Apply for Funding | Vet Partners Cares

Medical Care Funding Request Application

Pet Name

Pet Age

What is your pet?

Canine

Feline

Medical care and/or procedure needed

Estimated total cost

Doctor on case

Hospital requesting funds

Hospital phone number

Hospital email address

How much of the estimated total cost can you pay?

To receive financial care from VPC you must provide proof of financal need which could be Food Stamps, Unemployment, Social Security, Disability, or Most Recent Tax Return (income below poverty level)

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Your full name

Your address

Your phone number

Secondary contact full name

Secondary contact phone number

I hereby certify that the above statements are true and correct to the best of my knowledge. I understand that a false statement may disqualify me from receiving Vet Partners Cares funding. Furthermore, I release the State of Minnesota, the Board of Directors, officers, employees and agents for any loss, personal injury, accident, misfortune or damage to myself or my property. With the understanding that reasonable precautions shall be taken to ensure the health and safety of myself and my property.

I grant to Vet Partners Care, its representatives and employees the right to take photographs of my pet. I authorize Vet Partners Cares, its assignees and transferees to copyright, use and publish the same in print and/or electronically. By entering your signature below, you agree to the terms listed above.

Your signature

Date

Medical Care Funding Request Application

Thanks for submitting! Please remember to email drwoodward@vetpartners.com with your proof of financial need within 24 hours.