Patient Application

If you are in need of assistance in caring for your pet please click the link below to download the form, complete the form and send it to:

Companion Animal Relief Effort
121 Packerland Dr.
Green Bay, WI 54303

Please know that every effort will be made to approve your request for assistance. There are many factors that effect our decision, including availability of funds. Please be as thorough as possible on the application.

Service Member

Last Name:	First Name:	M.I:
Phone Number:	E-mail:
Address:
City:	State:	ZIP:
Branch of Service:	Rank:
Contact Person
Name:
Address:
City:	State:	ZIP:

Spouse/Significan Other's Information

Last Name:	First Name:	M.I:
Phone:	E-mail:
Address:
City:	State:	ZIP:
Employer
Company:	Contact Person:	Phone

Household Income Information

What is your gross household income?	$
What is your next expenditure amount?	$
What is your savings account balance for your household?	$
Do you receive any other financial assistance? If Yes, please list all and amount received:

Information About Military Service

When did you serve?
Where did you serve?
How long was your time of service?

Pet Information

Name:		Species:
Breed:		Color:
Sex:		Age:

Is someone else currently caring for your pet? Yes No

Person Currently Caring for Pet
Name:	Relation:
Address:
City:	State:	ZIP:
Phone:

Does your pet have any existing medical conditions? If yes, please explain:

Were you recommended by a Doctor to pursue medical attention? Yes No

Recommended by a Doctor
Dr.	Clinic Name:
Address:
City:	State:	ZIP:
Phone:	Fax:
E-mail:
Doctor Diagnois:
Doctor Recommendations:

Total Estimated Amount of Services:	$
Amount of Fund's Being Requested:	$

Please attach a narrative up to 2 pages as to why you believe the Foundation should fund you and your companion.

	I acknowledge that the Doctor performing the services and the C.A.R.E. for Service Members Organization are not responsible for the outcome of the surgery/services provided.
	I grant permission for C.A.R.E. to use my pet's pictures, story, and/or other medical information for the benefit of the foundation.
	I would be willing to talk to media regarding the assistance my pet and I have received from C.A.R.E.