VTH Gift Fund Application Version 2.0 / 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. Approvals are based on the following application in conjunction with the clinician's input of patient status and prognosis.

Owner Request

Owner First Name*

Owner Last Name*

Owner Birthday*

Owner Email*

Owner phone:*

Driver's License Nbr*

Address*

Please be sure to enter your full address including town, state, and zipcode.

Pet Name*

MR Record Number

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

Pet's age

Pet's species*

Pet's Breed

If breed is unknown please enter mixed.

Picture of Pet*

Please be sure to include a clear picture of your pet (nothing from the side, upside down,etc) and preferably alone (not with any humans or other pets)

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

Today's Date*

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

I hereby grant to KodiakCare Corporation the irrevocable and unrestricted right to use, reuse, publish, and republish my story and any photograph(s) and/or video of me and my pet, in whole or in part, and in conjunction with any printed matter, for editorial, advertising, promotional, trade, or any other purpose, without restriction. I hereby release KodiakCare Corporation and their legal representatives from any and all claims and liability relating to said photograph(s) and/or video, including without limitation any and all claims for libel, right of publicity, or invasion of privacy.

Instructions: Above is the release for KodiakCare Corporation. Owners are not required to complete the release to apply for gift funds, however if you do not complete the KodiakCare release, then KodiakCare funds cannot be utilized for your pet.

Please select preferred contact method

Please select preferred contact time

Note: This information will be used by KodiakCare Corporation should they need to contact you.

Please tell us about your current financial situations as it 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?*

Please provide any additional information on your financial need for veterinary care.

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.*

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