EmailMe Form - Violet's Friends - Assistance Request Form

Name *

First Last

Phone *

### - ### - ####

Email *

Address *

Street Address City State / Province / Region Postal / Zip Code Country / Region

Animal in need

Type *

Dog

Cat

Age *

Is your pet spayed or neutered? *

Yes

No

If No, please provide a reason why:

How long have you owned the animal? You must prove legal or medical documentation that the animal is your pet. *

Do you have pet insurance for the animal in need? *

Yes

No

Do you own other pets?

Yes

No

If yes, please list all pets and their ages

Have you adopted or rescued a pet in past 12 months?

Yes

No

Describe your animal’s case *

Estimated cost of treatment *

Treating Veterinarian

Name of Treating Veterinarian *

Name of Vet Hospital/Clinic *

Phone *

### - ### - ####

Email *

Address *

Street Address City State / Province / Region Postal / Zip Code Country / Region

Is this a specialty referral hospital?

Yes

No

Is the Treating Vet your primary vet or a specialty vet? *

Primary

Specialty

If Specialty Vet, who is your Primary Vet? Please enter name, address, and phone #

Background Family Information*

VFIN offers significant financial assistance to families in real need. Because of this, you must disclose combined household income of adults. We keep all information with the strictest confidentiality.

Number of people in family

Projected household income this year. Add together the income for ALL adult members of your household *

Last year’s household income. Enter the amount reported on your last year’s Tax Return for ALL adult members of your household. If you leave this blank or enter a range or any other character that is not a number, your request will be auto-denied *

Please check each option that applies to your current situation *

I am employed

I am unemployed or rely on government assistance

I do not breed dogs or cats (check this box is you have NEVER bred any of your pets)

I do not qualify for a credit card

If employed, please enter Company name and Job Title

If we require additional background family information, do you agree to provide this information upon request? *

Yes

No