KEPPT Medical Form
I confirm that I'm in the Las Vegas area, along with my pet.
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I agree
I confirm that this is for my pet only and is good for a one-time use. I understand that the Animal Foundation can only provide a specific amount of funds and may not cover my bill entirely. I understand that an operation may require a deposit of $100 or more.
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I agree
I understand that financial assistance is not for extensive surgeries, recurring treatments, late-stage cancer, and procedures that require a specialist.
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I agree
I understand that the Animal Foundation will NOT reimburse me for the operation and does NOT cover prior operations.
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I agree
I will NOT book an appointment with another veterinarian once I've completed this form.
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I agree
I understand that it can take between 48 to 72 hours for evaluation for my case.
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I agree
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Describe the pet's issues in detail
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How long has your pet had this issue?
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Days
Has the pet's issues gotten:
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Better
Same
Worse
Has your pet experienced any of the following:
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Lethargy
Not eating
Not drinking
Not going to the bathroom
Behavioral issues
None of the above
Other
If any of these apply, describe the issues in detail
Pet's current medications
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Has your pet had its vaccines?
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Yes
No
If so, where did they get their vaccine(s) (put in the administration date, the vet, and their phone number)?
Pet's name?
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Pet's species
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Cat
Dog
Other
Pet's breed
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If "other", describe the animal's species
Pet's age?
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Years
Pet's sex and altered status?
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Female
Female spayed
Male
Male neutered
Pet's weight
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Pounds
Pet's color
Upload any relevant images of the pet's issue(s), if applicable
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Upload an estimate from an accredited veterinarian here
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Name
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First Name
Last Name
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Email
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example@example.com
Date of birth
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-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How much are you able to afford for a potential operation?
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USD
Does any of the following apply to you:
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Military veteran
First responder
Senior citizen
Government assistance
None of the above
Have you been denied ScratchPay or CareCredit?
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Yes
No
Have you applied for other assistance and grants?
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Yes
No
If so, name the following grant(s) and assistance programs
[Who referred you to the KEPPT program?
Google
Hearts Alive or another animal shelter
Television/radio advertisement
Social media
Human support services
Animal Control
None of the above
Other
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I verify that all information sent over is correct.
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Please verify that you are human
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Submit
Submit
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