Application For Veterinary Care Financial Assistance

A completed application and proof of income must be submitted and approved prior to your appointment.

Application For Veterinary Care Financial Assistance

Wellness Clinic Financial Assistance Application.

"*" indicates required fields

First Name*

Last Name*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Email*

Phone*

How did you hear about us?*

Part 1: Pet Information

Pet Name*

Species*

Breed*

Gender*

Spayed/Neutered?*

Yes

Age*

Part 2: Medical Information

Medical Issue Needing Financial Assistance:*

Other Major Medical Issues:*

I am able to pay (enter dollar amount):*

I am applying for financial assistance from Routt County Humane Society for veterinary services for my pet in the amount of (enter dollar amount):*

Part 3: Financial Information

Annual Household Income:*

Number of Dependents:*

Employer:*

Length of Employment:*

Proof of Income Eligibility:*

Please upload evidence of income eligibility in the form of paystub, taxes, social security, social services programs. Note: We except the following file types: JPG, GIF, PNG and PDF. You may upload a maximum of five (5) files with a size limit of 40MB each.

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 40 MB, Max. files: 5.

Part 4: Signature

Signature*

I certify that all the above information is true and accurate to the best of my knowledge. I understand that services must be performed at the RCHS Wellness Clinic unless it is an emergency or a service that RCHS does not provide. I am also giving my permission for my veterinarian(s) to share information about my pet. I understand this information will be used to determine my eligibility for up to $500 in financial assistance and that any other fees beyond this amount will be my responsibility to pay.

Additional Comments

Permission to Share Your Pets Story*

Yes

Our grantors are interested in hearing stories of how pets were helped through this grant. Do we have permission to share your stories? No names will be used.

Privacy*

I agree to the Privacy Policy

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970-879-RCHS (7247)

Application For Veterinary Care Financial Assistance

A completed application and proof of income must be submitted and approved prior to your appointment.

Application For Veterinary Care Financial Assistance

HUMANE SOCIETY HOURS

WELLNESS CLINIC HOURS

Resources

Shelter Address:

Mailing Address:

Wellness Clinic/RCHS Offices:

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