A yes answer to any of these questions, will require documentation!!

                                  

                                                                                                   

                                                                                                              



             

                                                                                             

                                                                                           


                                                    Request for Assistance Application

                                                                   

You must apply for Care Credit (www.carecredit.com) before requesting assistance.   If approved, supply account # and amount.  If disapproved, copy of transaction #.  You need not accept it if approved.


Name


Address


Email Address


Phone number


Pet Name and age


Diagnosis


Treatment


Estimated Cost


Applicants will be asked if they are receiving any of the following:


* State or federally funded welfare program

* Food Stamps

* Medicaid

* Social Security

* SSI Disability

* Unemployment

* Non-commissioned active military

* Extreme medical expense, loss of home due to natural disaster, etc.


If approved for Care Credit, amount authorized:


If disapproved, transaction number:












    




                                   

                                                                                   


                                                                                                 
























Friends of Animals in Need

Please print and fill out the below Application.  Return to: friendsofanimalsinneed@gmail.com