Online Application

***PLEASE NOTE***This application works best in GOOGLE CHROME.  You can download here: https://www.google.com/chrome/

If you experience trouble submitting your application, please check to see if you are using a current internet browser such as google chrome, and have answered all application questions.  Most of these questions are required and your application will not submit without these required questions answered.

Welcome to the Online Application!  Completing and submitting this application is Step 3 of the process. Step 1 is to apply for Care Credit at www.CareCredit.com.   Before you begin the application process,  please ensure you have the following information READY and AVAILABLE to ensure your application is complete, accurate, and ready for submission.  For submission uploads, your documents will need to be saved and uploaded as PDF, WordDoc, or JPG.

After you have gathered the above information, proceed with the ONLINE application process below.  The online application typically takes about 20 minutes to complete if you have the requested information ready and available. This is the safest, fastest, most secure way to apply, and submits directly to our committee.  Please remember that a decision can take up to 1 Business WEEK.

If you do not upload financial documents as the application requests, your application will be placed on hold until your information is received.  Typically the forms will not allow you to submit your application without uploading these documents.  Be sure to have them ready!

All applications must be submitted ONLINE.  We can no longer accept applications via email, fax, or in-person delivery.  If you experience a problem with your online application, please email HealingPetsFoundation@gmail.com ATTN: IT SUPPORT.  Please allow up to 72 business hours for a response.

Application for Healing Pets Foundation

If you are human, leave this field blank.

Application for Assistance

Please have the following documents available for upload PRIOR to completing this application. We can accept PDFs, Microsoft/Google Docs, and JPGS for uploading. You must include proof of income, disability, and/or any state/federal assistance for you AND anyone who is your live-in spouse/partner/significant other, along with your approval or denial letter from Care Credit, including the key ID number.

Pet's Name *

Today's Date *

Have you asked both your SPECIALIST & Primary Care VETERINARIAN to complete assessments on our website? *

YES (Please ensure this task has been completed before proceeding with application)

Please request that both your primary care veterinarian and your specialist(s) submit their assessment forms through our website. These are needed to complete the application process. It is your responsibility to assure that your primary care veterinarian and specialist receive the request for their assessments. They can access the forms by visiting the “For Vets” tab on our HealingPetsFoundation.org homepage. You may also share our direct link to veterinary assessments with them: https://healingpetsfoundation.org/vets/

Care Credit Information

Completing this application is Step 2 of the qualification process. Step 1 is to apply for Care Credit. If you have not already applied for Care Credit, please visit their website at www.CareCredit.com. You will not be able to proceed with this application until you have received approval or denial from Care Credit and included this information in the following application. Please include Care Credit approval or denial information with this application.(Click to add description).

Care Credit Status *

Denied

Approved

Date of Care Credit Application *

Care Credit KEY ID *

This is located with your decision information from Care Credit and is typically 6 to 8 digits long. If you have trouble locating this number, please contact Care Credit at 1 (800) 859-9975.

Amount of Care Credit Approval *

Applicant's Basic Information

Name *

Is there a second household member - such as a spouse, significant other, partner, girlfriend/boyfriend that lives with you? *

YES

NO

Second Household Member Name and Relation *

Main Contact Number *

Additional Contact Number(s)

Address *

City *

State *

Zip Code *

Email *

Number of adults living in your household *

Number of children living with you *

Have you ever been convicted of animal abuse of neglect? *

Yes

No

If yes, you are not eligible for assistance through the Healing Pets Foundation

Pet's Information

Do you have full ownership and responsibility of this pet? *

Yes

No

Pet's Name *

Pet's Age *

Gender *

Male

Female

Breed *

Spayed/Neutered? *

Yes

No

Species *

Dog

Cat

How long have you owned this pet? *

Where did you get this pet? *

Please give a brief history of how this pet came to live with you. *

Pet's Medical Information

Do you have pet insurance for this pet? *

Yes

No

Please list the name of insurance company *

For what condition are you seeking assistance? *

Has your pet seen a specialty board certified veterinarian for this condition? *

Yes

No

If yes, please list the specialty board certification *

ACVS (American College of Veterinary Surgery)

ACVIM (American College of Veterinary Internal Medicine - can encompass Neurology)

AVDC (American Veterinary Dental College)

ACVEC (American College of Veterinary Emergency and Critical Care )

ACVO (American College of Veterinary Ophthalmologists)

ACVD (American College of Veterinary Dermatology)

Name of board certified veterinarian *

Name of specialty veterinary hospital and city location *

Please upload estimate/treatment plan for your pet provided by the board certified veterinary specialist

Uploading Files. Please Wait.

Drop a file here or click to upload Choose File

Maximum upload size: 104.86MB

Has your pet been evaluated by a general practice veterinarian for this condition? *

Yes

No

Name of your general practice clinic/hospital *

How recently did this evaluation take place? *

Is your pet currently hospitalized for this condition? *

Yes

No

Does your pet routinely see a (general practice) veterinarian? *

Yes

No

Applicants must have an established relationship with a veterinarian in order to qualify for assistance. Please note that your veterinarian will be contacted to confirm that they have treated your pet.

If no, why not? *

Are there any other pets in your family? *

Yes

No

If yes, how many, and what types? Please list all in the household. *

What is the anticipated cost of initial treatment through the specialist? *

Are there anticipated ongoing costs? *

Yes

No

Unknown

If yes, please describe ongoing costs. *

Employment Information

Total household MONTHLY income *

Include all sources, including your household partner/significant other.

Last YEAR'S household income, from all sources *

What is your primary source of income? *

Are you employed? *

Yes

No

If yes, how many hours per week? *

Name of Employer *

Employer Phone Number *

Are you receiving any public assistance? *

Yes

No

If yes, what type AND how often? *

Primary source of income for second household member (if applicable - if not applicable, record N/A) *

If this does not apply, enter N/A

Is he/she employed? *

Yes

No

If yes, how many hours per week? *

Name of his/her Employer *

Employer Phone *

Is he/she receiving any public assistance? *

Yes

No

If yes, how much AND how often? *

Financial Arrangements

How much are you able to put toward your pet's care? *

What is your ability or arrangment to pay for your remaining veterinary balance? *

Have you applied for financial assistance from other agencies (aside from Care Credit, including personal loans, credit cards, individuals, or other funding groups? *

Yes

No

Please Explain *

How much, if any, was received from these other sources? *

Do you have any family living in the area? *

Yes

No

Have you asked them to help you with your pet's veterinary care? *

Yes

No

Please Explain *

Have you or will you consider borrowing against your assets/belongings to pay for your pet's veterinary care? *

Yes

No

Please Explain. *

If your pet requires ongoing veterinary treatment (beyond the initial treatment and care), are your able and willing to support continued care for your pet? *

Yes

No

How will you pay for continued care? *

Additional Requirements, Uploads, & Authorization

UPLOAD SECTION INFORMATION: Please ensure you have your information available to upload. You will be unable to submit this application without submitting proof of income/assistance. PLEASE BLACK OUT OR SKEW ANY SECURE INFORMATION SUCH AS A SOCIAL SECURITY NUMBER. ALL WE NEED IS YOUR NAME AND ADDRESS ON THE FORMS TO VERIFY. This document can be via a scanned document or picture of a document if needed. FORMATS should be JPG, PDF, or Microsoft Word Document

REQUIRED: Upload your personal proof of income: a copy of your latest pay stub or most current W-2 *

Drop a file here or click to upload Choose File

Maximum upload size: 104.86MB

YOUR APPLICATION WILL NOT BE COMPLETE WITHOUT THIS UPLOADED.

REQUIRED: Upload your personal proof of income - this could be SSI benefits, Unemployment letter, or Retirement proof of income *

Drop a file here or click to upload Choose File

Maximum upload size: 104.86MB

YOUR APPLICATION WILL NOT BE COMPLETE WITHOUT THIS UPLOADED.

Required: Upload proof of assistance *

Drop a file here or click to upload Choose File

Maximum upload size: 104.86MB

Required: Please upload your secondary household member's (spouse/significant other/partner, etc) latest pay stub or W-2 *

Drop a file here or click to upload Choose File

Maximum upload size: 104.86MB

REQUIRED: Upload Proof of secondary household member's (spouse/significant other/partner, etc.) income: This could be SSI, Unemployment, or Retirement. *

Drop a file here or click to upload Choose File

Maximum upload size: 104.86MB

Upload proof of public assistance for secondary household member *

Drop a file here or click to upload Choose File

Maximum upload size: 104.86MB

IMPORTANT: If you have an estimate of any anticipated costs for future/ongoing specialty care, please upload here.

Drop a file here or click to upload Choose File

Maximum upload size: 104.86MB

The Healing Pets Foundation requires your permission to use your photo, pet’s photo and story in marketing and promotional materials – including but not limited to use on websites, blogs, flyers, brochures and fundraising materials. Do you agree to this requirement? *

Yes

Without your agreement, we will not be able to process your application.

If available, Please upload a photo of your pet.

Drop a file here or click to upload Choose File

Maximum upload size: 104.86MB

OPTIONAL & HIGHLY ENCOURAGED: Write and upload a Financial Hardship letter better explaining your situation and how Healing Pets Foundation can help you.

Drop a file here or click to upload Choose File

Maximum upload size: 104.86MB

UPLOAD VIA PDF, JPG or Microsoft Word Format

If you have any other information to upload that would show us your need for assistance, please upload here.

Drop a file here or click to upload Choose File

Maximum upload size: 104.86MB

This could be a foreclosure letter, bankruptcy letter, etc. Anything to show us your need! Upload in PFD, JPG or Microsoft Word Document

What will assistance from the Healing Pets Foundation mean to you? *

I certify that the answers on this application are true and correct, and understand if I willingly provide false answers, the Healing Pets Foundation will rescind any funds that have been applied toward my pet’s care, making me responsible to pay them. I understand the Healing Pets Foundation will take legal action to recoup the funding obtained under any fraudulent means. I understand that there is no guarantee I will receive funding and that I am fully responsible to pay for my pet’s care and fees/bills/invoices at all veterinary facilities visited regardless of the outcome of this application. If I am approved for funding and default on payment, Healing Pets Foundation has the right to rescind any funds that have been applied toward my pet’s care. Typing my full name serves as my signature, agreement, and understanding for this application. *

Type your first and last name for authorization and agreement.

All contact regarding your application will be via EMAIL. Please check your email through out the application process to ensure important information or instructions are not missed. Please allow up to 1 business WEEK after all information has been received for a decision. Please confirm your best contact EMAIL below. Thank you! *

Once you have submitted your information, provided we have received all necessary financial documents, etc, please allow up to 1 business WEEK to hear from our committee on a decision.  Our team communicates via email.  This application will require that you provide the best email address to contact you at.  PLEASE WATCH YOUR EMAIL FOR IMPORTANT INFORMATION REGARDING THE PROCESS.  Thank you!