Cause Fur Paws

Applicant Contact Information:
First Name
Last Name
Street Address 1
Street Address 2
City
State
Zipcode
Telephone Number
Email Address
Additional contact information you’d like us to know:
How did you hear about Cause for Paws?

Information About Your Pet:
If you are applying on behalf of a rescue group or other organization, please provide the name and contact information for your organization:
Organization Name:
Name of Dog:
Sex of Dog:
Color of dog:
How will you be sending your dog’s photo?
Approximate Age of Dog:	yrs
Approximate Weight of Dog:	lbs.
Has the dog been spayed or neutered?
If not yet, when will the dog be able to be spayed/neutered?
Is this dog on heartworm treatment preventative?
Is this dog current on all vaccinations?
Does this dog have any special needs (for example, special diet, medication, hearing impairment, vision impairment)?
If yes, please describe:
Has this dog had any history of biting another animal or a person?
If yes, and you are requesting assistance for a behavioral issue such as aggression or other serious issue, please thoroughly describe the problem here, along with interventions tried, and any trainer name and number, if applicable. You may then skip the Medical Information section, and proceed with the Funding Information section of the application.

Medical Information
Dog’s current location is:
Name of treating veterinarian:
Name of clinic/hospital:
Address:
City:
State:
Zipcode:
Telephone Number:
Fax Number:	(include area code)
Email address, if any:
What is the dog’s medical diagnosis?
Please provide a full description of the dog’s illness or injury and any alternate treatments that have been attempted:

What is the recommended course of treatment?
In the opinion of the treating veterinarian, what is the dog’s prognosis?
What is the estimated cost of this treatment?
What is the estimated cost of follow-up treatment, if any?
Has treatment already begun or been completed on this dog?
If yes, when?

Funding Information:
Please tell us any special circumstances or reasons why financial assistance is needed?
What attempts have you made to collect financial resources for this dog? If none, please explain why?
Did you apply for Care Credit?
What amount was approved?
If you did not apply, why not?
Have you discussed a payment plan with your veterinarian?
Have you contacted any other financial assistance organizations regarding this Dog?
If yes, identify the organization, contact person’s name and information, and summarize their response to your situation:
If no attempts have been made, please explain why?
How much have you already spent on this dog’s medical treatment for this illness/injury?
Cause for Paws funds are always limited, and we try our best to help as many dogs as we can. We hope that you will be able to pay at least a portion of this bill. How much will you or your rescue group be able to contribute to this bill?
Please specify the amount you are requesting from Cause for Paws:
Is the total of the two amounts above different from the estimated cost of treatment?
If yes, please explain:
If you are unable to contribute to this dog’s care, please explain:
If follow-up treatment is needed and exceeds the costs outlined here, how do you plan to pay for it?

For Rescue Organizations Only:
Was a rescue discount requested from the veterinarian?
Was the discount granted?
If yes, please explain the nature of the discount:
If the dog is in foster care, will the foster parent be responsible for any rehabilitation?
If not, or if this changes, what is your plan?
Why do you feel this procedure will make this dog more adoptable?
What is your rescue organization’s current bank account balance?
In the last six months, how many dogs has your organization rescued and re-homed?
Of those dogs, how many were seniors (over age 8)?
How many were medical needs dogs (requiring surgery or other medical treatment beyond typical spay/neuter, vaccinations)?