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TREATING PRACTICE/SPONSOR APPLICATION
STAT review for emergency care needed?
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Yes
No
Pet Name
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This pet is a
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Dog
Cat
Is pet awaiting treatment at your practice right now?
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Yes
No
Name of Treating Practice
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Practice Email
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Verify Email
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Treating Veterinarian Last Name
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Pet Owner Name
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First Name
Last Name
Comments or Concerns About Client Application
Do you recommend MHP Give Financial Support to this client?
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Yes
No
CLIENT INFORMATION
Are You The Primary Veterinarian For This Pet?
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Yes
No
Is Pet Current On Recommended Preventative Care?
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Yes
No
Don't Know
Length of time owner has been a client
Client generally compliant with veterinary recommendations? Describe here
PET INFORMATION
Briefly Describe The Nature Of Illness/Injury
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Is Abuse/Neglect A Consideration?
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Yes
No
TREATMENT PLAN
Prognosis With Plan
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>75% (Good to excellent)
>50% (Fair to good)
<50% (Poor)
Detailed Treatment Estimate
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Miscellaneous Support Document
Miscellaneous Support Document #2
Veterinary Signature (Type Treating Veterinarian's Name)
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