Name and Age of Pet Owner:

Type of Disability and/or Occupation:

Address(Street, Apt., City, State, Zip):

Phone No.(home/work/cell):

Description of Pet (name, type-dog/cat/etc, age):

Description of Medical Treatment/Symptoms/Injury:

Name, Address, & Phone No. of Animal Hospital/Veterinarian:

Estimated Cost of Treatment:

Amount you can contribute:

I, am the legal owner of the above-described pet. I attest that the information I have provided is accurate and complete. I give my consent for the above-mentioned medical care. I understand that HELP-A-PET assumes no liability and makes no assurances as to the appropriateness, quality, or outcome of any medical diagnoses, treatments, products and services. I consent to HELP-A-PET using pictures of my pet and its owner(s) as well as a description of the medical care for the purposes of promotion and fund raising. I understand any documentation or pictures given to HELP-A-PET cannot be returned

Signature:

Date:

DUE TO LIMITED FUNDING, A PET OWNER CAN ONLY RECEIVE FINANCIAL ASSISTANCE ONCE PER PET.