VTH Gift Fund Application / New Form

Instructions

Through the UI Foundation, the Veterinary Teaching Hospital receives limited monetary donations that are designated to assist clients in helping to pay for hospital services for cases that meet specific criteria. University of Illinois employees are not eligible. Approvals are based on the following application in conjunction with the clinician's input of patient status and prognosis.

Owner Request

I acknowledge that clients may only receive financial assistance once, must contribute to the overal cost and commit to the pet's follow-up care.*

Owner First Name*

Owner Last Name*

Owner Email*

Owner phone:*

Driver's License Nbr*

Pet Name*

MR Record Number

Please enter the University of Illinois Medical Record number if your pet has been previously seen and known.

Are you a University of Illinois Employee?*

Yes

University of Illinois Employees are not eligible. You should not submit this form.

Have you applied for Care Credit?*

Yes

Were you approved or denied?

Approved

Denied

What is you Care Credit limit?

Do you qualify for one or more of the following (check all that apply):

SNAP

State or Federally Funded Welfare Program

Medicaid

Social Security

SSI Disability

Unemployment

Non-Commissioned Active Military

Have suffered an extreme medical expense, loss of home due to natural disaster, or other hardship

What is the estimate of cost for your pet's care?*

Please tell as about your current financial situations as relates to paying for your pet's care:

How much are you able to contribute today towards your pet's care?*

How much are you able to contribute in the next 30 days towards your pet's care?*

How much have you paid in veterinary care at other facilities related to these symptoms/diagnosis?*

How will you manage the necessary follow up care for your pet?*

Owner allows their case to be (anonymously) shared with the donor of the Gift Fund as well as in VTH publicity (i.e. photograph of patient, brief history, and outcome testimonials) if treatment is successful.*

I am ready to submit my request.*

VTH Gift Fund Application

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Instructions

Owner Request

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