Financial Assistance Application If this is an emergency, please call the Life Centre in Leesburg at 703-777-5755 or Blue Ridge Vet in Purcellville at 540-338-7387 in addition to completing this form.Is this an Emergency?* Yes No Name* First Last * Email* Phone*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code How did you hear about us?*WebsiteEmailFacebookOther Social MediaWord of MouthEventOtherHardship*DisabilityIllnessLimited IncomeUnemploymentOtherType of Animal*BirdCatDogGuinea PigRabbitOtherHiddenBreed of Animal Pet's name* Pet's Age* What medical issue is your pet having?*Vet's Name* Vet's Phone*Have you already seen a veterinarian?* Yes No Estimate of cost, if received Is the pet spayed or netuered?* Yes No Do you agree to have your pet spayed/neutered within 30 days of approved financial assistance?* Yes No Are there other pets in the home?* Yes No Are these pets spayed/netuered?* Yes No Due to budget limitations, we ask that you pay a portion of the invoice. Do you agree to help so that we may also assist others?* Yes No How much can you afford to pay towards the invoice?* I agree to follow all HSLC guidelines set forth in this financial assistance application. (Electronically Sign)* Date* MM slash DD slash YYYY
