Request for Veterinary Approval

To be completed by veterinarian or staff.

Because we rely upon the judgement and experience of the veterinarian to guide our funding decisions, we ask that each vet complete a short form to become registered with us prior to working together. This allows us to become familiar with you and you with us. Please complete and submit this form along with a copy of your veterinary license. Please submit via this website, fax: 859.201.1177 OR email: beth@FriendsandVetsHelpingPets.org.

Download a printer-friendly version of this form for mailing/faxing.

Veterinarian's Full Name:*
Animal Hospital Name:*
Animal Hospital Address:*
Street Address Address Line 2 City State ZIP Code
Animal Clinic/Hospital Email*
Animal Clinic/Hospital Phone Number:*
Animal Hospital Website:
Provide the animal hospital's EIN number.*

We are required to file an information return with the IRS to report income paid to you and must obtain your TIN or EIN to do so.
Please fax, email, mail or upload your Veterinary License?*
- I will fax a copy of my Veterinary Licence to 859.201.1177.
- I will email a copy of my Veterianary License to info@friendsandvetshelpingpets.org
- I will mail a copy of my Veterinary License to Friends & Vets Helping Pets, P.O. Box 910117, Lexington, KY 40591
- I would like to upload a copy of my Veterinary License.
Please attach a copy of your Veterinary License. (PDF or JPG)*
Accepted file types: pdf, jpg, tif, jpg, pdf, tif, png, png, jpeg, jpeg, Max. file size: 50 MB.
Please list any specialized areas of practice in which you are certified or have experience. Provide copies of certifications, if applicable
List community involvement including volunteer work, memberships in community organizations (BBB, Rotary Club, etc.).
List professional organizations with whom you or your clinic maintain membership.
Will you fax, mail or upload your Curriculum Vitae?
- I will fax a copy of my Curriculum Vitae to 859.201.1177.
- I will email a copy of my Curriculum Vitae to info@friendsandvetshelpingpets.org
- I will mail a copy of my Curriculum Vitae to Friends & Vets Helping Pets, P.O. Box 910117, Lexington, KY 40591
- I would like to upload a copy of my Curriculum Vitae.
Please attach a copy of your curriculum vitae. (PDF, DOC, DOCX or RTF)
Accepted file types: pdf, jpg, tif, jpg, pdf, tif, png, png, jpeg, jpeg, doc, doc, docx, docx, rtf, rtf, Max. file size: 50 MB.
By submitting this Request for Veterinary Approval Form, I am stating under penalty of fraud that all of the facts contained herein are true and accurate. With my signature herein below, I am expressing my intent to work closely with clients to determine and refer those who are in need of financial assistance, and to work with Friends & Vets Helping Pets to help said clients by donating a portion of my time to reduce costs incurred.
Date:
MM slash DD slash YYYY
Signature:
Email
This field is for validation purposes and should be left unchanged.

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