Pet Information Form

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 and submit the Pet Information Form with your itemized estimate for treatment so that Friends & Vets Helping Pets may process your client’s application for financial assistance. 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:*
Name of Clinic/Animal Hospital:*
Clinic/Animal Hospital Address*
Street Address Address Line 2 City State ZIP Code
Veterinarian's Email:*
Veterinarian's Phone Number:*
Owner's Full Name:*
Owner's Email:*
Owner's Phone Number:*
Pet's Full Name:*
Pet Species & Breed:*
Pet Age:*
Diagnosis:*
Prognosis with Treatment:*
Treatment Already Provided: (Please send copy of the pet’s file or applicable test results if requested. They can be scanned and emailed if convenient.)*
Treatment still needed:*
How soon can treatment occur if funds are available?*
Is the pet receiving proper care?*
Treatment Estimate: Please attach an itemized, written estimate for the cost of treatment. As we are a nonprofit organization, FVHP asks participating veterinarians to donate a small portion of their time or services on each approved treatment, typically 15-25%, in an effort to reduce the cost of the treatment.
Please include the amount you are willing to donate in the estimate. Friends & Vets Helping Pets funds treatments for curable (lifesaving, not life prolonging) illnesses, injuries or conditions such as tumors, broken bones, ambulatory care, expensive medication, or post-surgical prosthetics such as a K-9 cart. FVHP does not fund preventative measures or diagnostics like x-ray, ultrasound or MRI tests.

If you would prefer, please fax this information to 859.201.1177 OR email: beth@FriendsandVetsHelpingPets.org.
Treatment Estimate:
- I would like to fax my estimate to 859.201.1177.
- I would like to email my estimate to info@friendsandvetshelpingpets.org
- I would like to upload a digital copy of my estimate.
- I would like to enter my estimate via this form.
Upload Your Estimate (PDF, JPG, DOC, DOCX or RTF):*
Accepted file types: jpeg, jpg, jpeg, jpg, pdf, doc, docx, rtf, pdf, doc, docx, rtf, Max. file size: 50 MB.
Enter your estimate:*
Our Process:

Friends & Vets Helping Pets has a carefully designed application process that begins online at www.FriendsandVetsHelpingPets.org. All applicants must be prepared to show documentation of financial need at this time. During this process, we work with the applicant to see how much they can afford to pay. Because we rely upon the judgment 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. The veterinarian submits a diagnosis/treatment protocol and cost estimate of the treatment for the pet. As we are a 501c3 nonprofit, FVHP requests that the veterinarian donate a small portion of their time or services on each approved treatment, typically 15 – 25%, in an effort to reduce the cost of the treatment. This allows you to help the family/pet and still make a profit. Please include the amount you are willing to donate in the estimate. Next, depending on availability of funding, we provide the difference in the form of a grant paid directly to the veterinary clinic/hospital treating the pet. By working together as a team, these lifesaving surgeries and treatments become more affordable and all parties have a vested interest in the outcome.

Friends & Vets Helping Pets funds treatments for curable (lifesaving, not life prolonging) diseases such as tumors, broken bones, ambulatory care, expensive medication, or post-surgical prosthetics such as a K-9 cart. These treatments are not typically covered by most animal welfare groups. FVHP does not fund diagnostics or preventative measures like x-ray, ultrasound or MRI tests.

Payment Terms

Friends & Vets Helping Pets cannot assist with charges incurred prior to written approval of this application and the client's application. If your client is approved for financial assistance by Friends & Vets Helping Pets, you will receive written notification including specific amounts that Friends & Vets Helping Pets agrees to pay. Once permission has been given with the terms expressly set out therein, Friends & Vets Helping Pets will remit payment directly to the clinic by check via USPS following completion of treatment and receipt of your invoice via email or mail to the previously agreed upon cost.

Please Sign Below

By signing below, you affirm that you understand and agree to accept Friends & Vets Helping Pets’ payment terms, as outlined in the paragraph above. If you have any questions, call 859.309.2043.
Signature:*
If you are completing this form on a touch device, sign using your finger or a stylus, otherwise, use your mouse or other pointing device to sign your name.
Date:*
MM slash DD slash YYYY
Name/Title:
Email of Hospital Administrator where formal notification may be sent:*
Enter Email Confirm Email
Name
This field is for validation purposes and should be left unchanged.

Our Process:

Payment Terms

Please Sign Below

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