Compassionate Care Fund - Funding Request
Please complete the form below in as much detail as possible to let the Compassionate Care Fund approval committee know the reason for why funds are being requested for your case. An approval committee member will contact you shortly.
Name of DVM requesting funds:
NAH location at which pet's care is taking place:
Please select
39th/Holistic
Newberry
Main Street
Springhill
Please select
Pet's Name:
Owner's Name:
Amount of funding requested:
Please do not exceed $500
Brief history of ailment/injury:
What is the pet's prognosis?
Any follow-up or long-term care required?
Yes
No
If yes, please explain:
Has the treatment plan and estimate been reviewed with the owner of the pet?
Yes
No
Has the owner applied for Care Credit and Scratch Pay?
Yes - denied for both
Yes - approved but has used all available funds
No
Has the owner paid an exam fee?
Yes
No
SUBMIT FORM
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