March 8, 2017 adminHR CACS Medical Assistance Form Your Name (required) Street Address (required) City (required) State (required) Zipcode (required) Your Email (required) Describe Pets Needing Medical Assistance. (required) My pet has been seen and examined by a vet: (Note: All pets applying for financial assistance for a procedure/medication/service must have a valid record with a vet, medical direction for the procedure, and documentation to corroborate claim and cost.) Yes, they have seen a vet.No, they haven’t seen a vet. If not seeing a vet, Why? My vet has provided an exam for the pet, has indicated that a procedure/medication/service is required, and has provided documentation showing the procedure/medication/service, cost, and necessity: YesNo Procedure/Medication/Service: (required) Estimated Cost for Above Procedure/Medication/Service: $ My documentation is attached to this application and details date of exam, need, and estimated cost. It is signed by the veterinarian and dated within 15 days or less of this application: YesNo Reason for requiring financial assistance: I have the ability to care for the animal post Procedure/Medication/Service, mentally, financially, and time wise: Yes, I can provide reasonable and appropriate care.No, I cannot provide reasonable and appropriate care. Finally, please indicate any outstanding debts that are a direct result of the animal care provided to this pet, including but not limited to: the initial exam by a vet, other procedures, continued care. Note, this is not with regard to basic necessities such as food and other basics. Yes, I have outstanding medical and care debt.No, this is the first time I have required assistance. Amount $ I certify that all of the information included in this application is correct, to the best of my knowledge, and there is no attempt at fraud, misinformation, or other illegal activity. Thank you for your application. Please ensure that all needed documentation is attached and signed/dated appropriately – this will speed the process up greatly. The application will be reviewed by the staff at Harmony Rescue, Inc. and you will be contacted if more information is needed, or to notify you of approval/denial. Note that this process can take 1-2 days, depending on the specific need and information provided.