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.
Pet Name and age
Applicants will be asked if they are receiving any of the following:
* State or federally funded welfare program
* Food Stamps
* Social Security
* SSI Disability
* 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:
A yes answer to any of these questions, will require documentation!!
Please print and fill out the below Application. Return to: email@example.com