Veterinarian’s Pet Information Form (VPIF)

Veterinarian's Pet Information Form (VPIF)

About The Pet
What is the client or contact name?*
First Last
Is this grant request for an individual or a rescue organization?*
- Individual
- Rescue Organization
In your opinion, do you believe this client is a good candidate for a Broken Tails grant?
- Yes
- No
Explain why?
Pet's Name*
First Last
Diagnosis:
Treatment already provided:
Treatment still needed:
Prognosis with treatment:
In your opinion, will the pet die or need to be euthanized within 10 days if not treated?
- Yes
- No
Explain why:
Is the pet hospitalized now?
- Yes
- No
Will the pet remain hospitalized until treatment?
- Yes
- No
How soon could the treatment occur if funds became available?
What is the longest the pet can wait for treatment?
Is the pet spayed/neutered?
- Yes
- No
If not, can they be spay/neutered now?
- Yes
- No
Any other comments about this client or their pet?
About Costs And Payment Options
Estimated cost of Treatment
Note: If the pet can be spayed/neutered at this time, please include the itemized cost in your estimate
Does your office accept CareCredit?
- Yes
- No
Did this person apply at your office?
- Yes
- No
What was the result?
- Approved
- Denied
If approved, for what amount?
Payment Terms and Signature

Broken Tails cannot assist with charges incurred prior to approval of application. If your client is approved for a grant, Broken Tails will remit payment by check via USPS following completion of treatment and receipt of your invoice. By selecting ‘I Agree' below, I affirm that I understand and accept Broken Tails requirements, payment policies, as outlined above and detailed on the Grants page.
It also certifies that the information I have supplied above is true and that any false statements may result in nullifying this application. I further understand that this application is the property of Broken Tails and will be retained by them. By selecting ‘I Agree’ below, it constitutes an electronic signature that is valid and a legal substitution for my written signature.
Name of hospital or clinic
If you choose "Other," please explain:
Other Clinic Email
Enter Email Confirm Email
Other Clinic Phone
Name of Vet
Name of Vet
Note: only pre-approved Veterinarians can submit applications. Contact us to see if you qualify for pre-approval.
Clinic contact person
Clinic contact person
Clinic contact person email address
Clinic Phone
Clinic Phone
Date
By checking this box you have read and agree to the above statements*
- I agree
Captcha

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