ART is determined to not only find homes for homeless pets, but also to help families keep their beloved animals when life hits a rough spot financially. ART’s Community Medical Assistance Program is designed to provide routine veterinary care, such as updating shots and heartworm tests to qualifying families. We can assist with, and sometimes pay for, diagnostic testing and surgeries. It is the organization’s goal to help families keep their pets healthy, in their home, and out of the shelter system.

If you need Medical Assistance, please complete this form.

Please put N/A when the question does not apply to you. Your application will need to be done again if not complete.

CONTACT INFORMATION

Applicant First and Last Name (required):

Street Address (required):

Suite, Condo, Apt:

City (required):

State (required):

Zip (required):

Home Phone (required):

Cell Phone:

Your Email (required):

How did you hear about us?

Have you received help from us before?

If so, when?

What other organizations have you contacted for help?

Are you employed?
 Yes No

Place of employment:

Do you receive assistance from any government program? If so please specify:

Do you have any other source of income?

What is the household monthly income?

Have you applied for Care Credit?

Please list any alternate funds that you may access such as credit cards, personal loans, etc:

Is there anything else that you would like to add concerning the need for financial assistance?

How much can you contribute to the vet care?

Upon request will you be able to send pictures of your pet?
 Yes No

It is important for us to keep our donors informed. Are you willing to send pictures and updates of your pet during recovery and after treatment?
 Yes No

PERSONAL REFERENCE

Personal Reference Name (not family)

Personal Reference Phone

Personal Reference Email

PET'S INFORMATION

Please list all dogs currently living in your home:

Are the dogs spayed or neutered?

Please list all cats currently living in your home:

Are the cats spayed or neutered?

Pet(s) Name Needing Assistance:

Breed(s):

Approximate Age(s):

Approximate Weight(s):

Has this pet been spayed or neutered?

*If your pet is not spayed or neutered, we will require this be done at the conclusion of treatment.

Does your pet spend the majority of its time indoors?

Please give the date and place your pet was last seen by a vet:

Do you have paperwork to document your dog/cat is updated on vaccines?

Please list your current vet and his/her phone number:

Please describe your pet’s need for medical attention including how and when the problem started?

Has your pet received any treatment from a vet for this condition?

Please give name and number of vet if this is not your regular vet:

Do you have transportation?

Any other information you would like to add?

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