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 OptionsEstimated cost of Treatment Note: If the pet can be spayed/neutered at this time, please include the itemized cost in your estimateDoes 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 clinicChoose OnePort Royal Veterinary HospitalRiverwalk Animal HospitalOther ClinicsIf you choose "Other," please explain:Other Clinic Email Enter Email Confirm Email Other Clinic PhoneName of VetChoose oneDr Marikay Campbell - PRVHDr Jeanice LaneDr Michelle MartinDr Eden StarkName of VetChoose oneDr Stacy O'QuinnDr Joshua MitchumDr Kimberly CarperNote: only pre-approved Veterinarians can submit applications. Contact us to see if you qualify for pre-approval. Clinic contact personJennifer HamptonClinic contact personYvonne HodgesClinic contact person email addresshospital@prvhsc.comClinic Phone843 - 379 - 7387 - PRVHClinic Phone843 - 987 - 0844Date MM slash DD slash YYYY By checking this box you have read and agree to the above statements* I agree Captcha
