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

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.    You need to provide the application key or reference # to Friends..  You do not have to be approved by Care Credit, you only have to apply.

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: