Name of Pet
Species:
Breed:
Gender:
Male
Female
Age
Spayed/Neutered?
Yes
No
* Service Animal?
Yes
No
*Based on the definition under Title II of the
Americans with Disabilities Act, a service animal is a dog or
miniature horse, individually trained to perform tasks related to
the person’s disability.
If yes, what tasks has the animal been trained to do
for you?
Describe your pet's medical issue:
Has the animal been seen by a veterinarian?
Yes
No
Name of Veterinarian/Veterinary Clinic
Address of Veterinarian/Veterinary Clinic
Phone Number of Veterinarian/Veterinary Clinic
Date of last exam
Estimated cost of treatment
PLEASE UPLOAD VETERINARIAN DOCUMENTATION
HERE:
OR EMAIL VETERINARIAN DOCUMENTATION
TO
petcare@harleys-hopefoundation.org
Species and number of other pets in the
household:
Are all other pets spayed or neutered?
Yes
No
If “No” and the
animal is over one year old, you do not qualify . Do
not proceed with the application. The only exception to this policy
is if your veterinarian provides documentation that the animal has a
medical condition that makes spaying/neuter a high risk procedure.
Are cats kept indoors?
Yes
No
If no, please explain
Are dogs kept outside?
Yes
No
If yes, please explain
Are dogs kept chained?
Yes
No
If yes, please explain
Do dogs ride in the back of trucks?
Yes
No
If yes, please explain
If your pet's injury was caused by unsafe or
unsecured home environment, are you willing to correct the
condition?
Yes
No
If not, please explain
Some things you can do:
Keep debris, sharp objects, toxic substances, pesticides out of yard
Cover electrical cords
Anchor heavy objects to wall
Secure fenced area so your pets are not allowed to roam free
Do you provide your pets with regular veterinary
care?
Yes
No
If no, please explain why not:
When is the last time your pet was seen by a
veterinarian for a full wellness exam?
(If your pet
has gone more than 18 months without seeing a veterinarian,
you do not qualify . Please do not complete the application.)
This is equivalent to 10 years without seeing a human doctor .
Name of Veterinarian/Veterinary Clinic
Address of Veterinarian/Veterinary Clinic
Phone Number of Veterinarian/Veterinary Clinic
(Applicants must have an established
relationship with a veterinarian in order to qualify for assistance.
Please note we may contact your veterinarian to confirm that they
have treated your animal. If you have recently moved and have not
yet found a veterinarian in your new location, please list your most
recent veterinarian.)
In the case of veterinary treatment/surgery, are you
capable of and willing to continue caring for this animal?
Yes
No
Please explain how will you will finance this
continuing care if you cannot afford to pay for emergency/major
treatment?
If you are applying for help with a chronic
(ongoing) health condition, what is your plan for paying for ongoing
care for your pet? Continued application to charities is not an
acceptable answer as most charities will not support any one animal
in need.
Please note that additional veterinary expenses can
occur post-treatment that are not covered by HHF. These expenses may
include follow-up care with your regular veterinarian, oxygen
treatment, surgery, and rehabilitation. Are you prepared and willing
to follow-through with the full prescribed course of treatment,
and agree not to euthanize your pet once treatment has begun except
on the advice of the attending veterinarian ?
Yes
No
If you are not able to care for your pet, are you
willing to surrender said pet to another party that can provide
care, including a legitimate, limited admission animal rescue?
Yes
No