Financial Assistance Application -

Search for:

Social Media

Adopt
About Us
Volunteer
Programs
Resources
Donate

Financial Assistance Application

Company
This field is for validation purposes and should be left unchanged.
Is this an Emergency?*
- Yes
- No
If this is an emergency, in addition to completing this form. please call the Life Centre in Leesburg at 703-777-5755, Blue Ridge Vet in Purcellville at 540-338-7387, or one of the other vets listed on our urgent vet care page.
Do you live in Loudoun County, VA?*
- Yes
- No
This service is only available to Loudoun County, VA residents.

If you do not live in Loudoun County, see help with your pet for other resources.
Name*
First Last
Email*
Phone*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
How did you hear about us?*
Hardship*
Type of Animal*
size*
- small
- medium
- large
Approximate Weight*
This field is hidden when viewing the form
Breed of Animal
Pet's name*
Pet's Age*
What medical issue is your pet having?*
Regular Vet's Name*
Regular Vet's Phone*
Have you already seen a veterinarian about this issue?*
- Yes
- No
Did you see your regular vet?*
- Yes
- No
Vet you saw for this issue*
Vet's Phone*
Phone number for the vet you saw for this issue
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

Sitemap

Adopt
About Us
Volunteer
Programs
Resources
Donate

Contact Us

ADDRESS: PO Box 777 Leesburg, VA 20178 EMAIL: helpanimals@humaneloudoun.org
SITE: humaneloudoun.org

Social Media

Search for:

Keep Informed

Want to keep informed? Sign up for our newsletter.

Non profit website design by Elevation