Assistance Request Form

Community Assistance Application

Please complete this form to apply for financial assistance.

MM slash DD slash YYYY
Name(Required)
Address(Required)
Section 1: Financial & Assistance Status(Required)
Section 2: Pet & Care Needs (select all that apply)(Required)
Which option best describes your current financial situation?(Required)
I am seeking assistance for which of these services at this time (select one service)(Required)

Is you pet spayed or neutered?
Species

Do you have reliable transportation to bring your pet to the clinic for their appointment?
Do you have a regular veterinarian that your pet has seen in past?
Please read below statements:(Required)
I understand that the Louisiana SPCA Community clinic is not an emergency veterinary hospital or full service veterinary hospital. Some applications for assistance will be outside of the scope of care the Community Clinic is able to provide. By submitting this application I understand that I am responsible for seeking emergency care for my pet when needed. Application take up to 10 business days to review and are dependent on funding availability.
Please review the following statement(Required)
Applying financial assistance for your pet is limited to availability of funding and resources and may not be available on an ongoing basis. Financial support received for this visit once this application is submitted may not apply to follow up visits or visits for other pets.
Please read the following statement(Required)
I allow the Louisiana SPCA to contact me via phone or email with follow up questions regarding this application and the needs of my pet.
Would you like to join our email list?(Required)

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