– Apply for Assistance

Pet Owner Information

Name of Pet Owner(required)

Street Address(required)

City(required)

State(required)

Zip Code(required)

Phone

Email address(required)

Are you the legal owner of the pet described below?

Yes

No

If No, please explain:

How did you hear about DaisyCares?

Veterinary Information

Vet's Name(required)

Street Address(required)

City(required)

State(required)

Zip Code(required)

Phone(required)

Fax

Email address

Upload Veterinary Estimate

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The veterinary estimate must include treatment plan. Keep in mind that DaisyCares DOES NOT cover exams or testing. Only JPEG allowed. PDF and other formats can be emailed to DaisyCares after form is submitted. Maximum size 10MB

Financial Hardship

Describe your financial hardship:(required)

Upload Proof of Financial Need

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Only JPEG allowed. PDF and other formats can be emailed to DaisyCares after form is submitted. Maximum size 10MB

Send to DaisyCares by email or mail, or provide a copy to the treating Veterinarian (with permission to deliver to DaisyCares), any of the following information that supports your financial hardship: a copy of your latest check stub; a copy of your current unemployment benefits; a copy of your latest tax return; a copy of your latest bank statement; a copy of any SSI benefits; a copy of an unemployment benefit letter; a copy of your latest W-2 or 1099 from a current employer; evidence that you are residing at a homeless shelter; or any other reasonable supporting evidence of financial inability for consideration by DaisyCares on a case by case basis). Your application will not be considered complete until evidence of hardship is provided to DaisyCares.

I attest as follows:
All of the information I have provided to DaisyCares (or caused to be provided to DaisyCares) is true, complete and correct. I have reviewed the Qualification Criteria, and satisfy the requirements for qualification set forth therein. I am asking DaisyCares for a grant of in the amount set forth above, to be paid directly to my Veterinarian listed above or a Veterinarian referred to me by DaisyCares. I agree to pay the remainder of the cost of the medical care to the Veterinarian listed above or the Veterinarian referred to me by DaisyCares, as a condition to the grant. I give my consent for the above mentioned medical care. I understand that DaisyCares assumes no liability and makes no assurance as to the appropriateness, qualify or outcome of any medical diagnosis, treatment, products or services. I further agree that DaisyCares has no agency relationship with the treating Veterinarian, whether or not referred to me by DaisyCares. I consent to allow DaisyCares the use of any pictures, and description of medical care for the purposes of promotion and fundraising.

Application will only be processed when you click “Submit Application” and provide your evidence of hardship as requested above. No applications will be processed via mail or fax, unless waived by DaisyCares in its sole discretion.

The DaisyCares Veterinary Care program has a limited monthly grant capacity and is subject to availability of funds.