Please fill out the form below to apply for financial aid. Pet Owner Information Last name First name Address Phone number Alternate phone number Your Date of Birth Email address Pet Information Name of Pet Age Breed Pet's weight lbs Sex Intact Female Intact Male Spayed Female Neutered Male Reason for Euthanasia Veterinarian information Veterinarian name Name of veterinary hospital Veterinarian phone number Date of last veterinarian visit Diagnosis Veterinarian recommendations Any other veterinarians your pet has seen in the last 2 years? May we contact your veterinarian? Yes No Financial information Annual income Amount you are able to contribute for the service $ Amount of financial aid you are applying for $ Amount of financial aid you are applying for - Description Please have our Client Care Specialist give you a full quote for the service including:EuthanasiaAftercarePaw Print (if desired)Travel feeAny applicable after-hours feesAny ashes delivery fee applicableThe amount of financial aid you are applying for is the total amount of the quote minus the amount you are able to contribute as per above. Example: Total quote including all the items above $795. The amount you are able to contribute is $400. The amount of financial aid you are applying for would be $395. Please tell us why you need the financial assistance You and your pet Please tell us about your relationship with your pet Tell us why you are opting for a home euthanasia Please give us any additional information which would assist us in making a decision regarding providing you with the requested financial aid Additional instructions Agreement Home Pet Euthanasia is under no obligation to provide financial aid to anyone applying for it. I agree to provide my share of the payment as per "amount I am able to contribute" above prior the doctor's arrival. I agree to pay for the cancellation fee ($200) if I was to cancel the appointment within 2 hours of the appointment time. The $200 cancellation fee (when applicable) will be taken from the amount I agreed to contribute, and not from the financial aid amount. I also agree to have a memorial for my pet in the Iggy Memorial Fund section of the Home Pet Euthanasia website and I agree to send a photo of my pet along with a short memorial text. I agree I agree I understand and agree to the above terms and conditions. I agree for Home Pet Euthanasia to contact my veterinarian regarding my pet's condition, diagnosis, current and past treatments and recommendations. Electronic Signature Please make sure you hit submit at the bottom of the form. In addition, please email a photo of your pet to [email protected] Date
