Grant Request

Once you have successfully submitted this form, you will received a return copy via email for your records. Any questions or difficulties please call Juli Burnell 937-657-6878

Please fill out form completely

Today's Date(Required)

Date of Service(Required)

Member Practice

Practice Name(Required)

Practice Email(Required)

Patient Information

Patient Name(Required)

Patient Name

Age(Required)

Species(Required)

Sex(Required)

Male

Female

Altered(Required)

Yes

Client Information

First Name(Required)

Last Name(Required)

Street Address(Required)

Address 2

City(Required)

State(Required)

Zip(Required)

County(Required)

Phone(Required)

Email Address(Required)

Referral Information

Referral Information(Required)

Our goal is to keep pets and their families together; Is this pet treated as part of the family? How does the family count on the pet (examples: companion for elderly? Autistic child? Help combat anxiety? Depression? PTSD?) 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?

Diagnosis, Medical Reason for referral.(Required)

Cost of Treatment

Cost of Treatment(Required)

Please email an invoice for services to [email protected]. This is needed to accompany the grant request.

Less Discount to ERDF(Required)

Less Client Contribution(Required)

Funds Requested(Required)

Authorized By:(Required)

REMINDER: Please make sure the client receives our brochure explaining the fund and knows to look for an email welcome letter from us. Tell them it’s required that they fill out the electronic form reached via link through this letter. (If they have no email, have them fill out a paper copy before leaving). If you can take a photo of the pet at the time of their visit, please do so and send it to us at [email protected]. THANK YOU! * Please check your spam folder for a confirmation email.

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