Grant Request

    Member Practice

    Patient Information

    Sex:MaleFemale
    Altered:YesNo

    Client Information

    Referral Information

    Our goal is to help keep pets and their families together; is this a situation in which the companion animal is considered a part of the family? Will the client’s lack of available funds result in their companion animal not receiving the care necessary to maintain the best health outcome, having to be surrendered or euthanized?

    Medical Reason for Referral

    Cost of Treatment

    Estimated Cost:*

    Less Discount to ERDF:*

    Less Client Contribution:*

    FUNDS REQUESTED:*

    Authorized By:*

    REMINDER: Please make sure the client receives a copy of our letter and brochure explaining the fund. If you can take a photo of the pet at the time of their visit, please do so and send it to us at info@elliesrainydayfund.org. THANK YOU!