One moment please...
Name
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First Name
Last Name
Mailing Address
*
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
County
*
select one
Santa Cruz
Monterey
Phone
*
Email
*
Verify Email
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Is there an alternate contact for this case?
*
Yes
No
Alternate Contact Name
First Name
Last Name
Additional Phone
Which of the following apply?
This information is optional and helps us with future fundraising.
Unemployed
Disabled
65 or over
Active Military
Veteran
Student
Homeless
None
How did you hear about BirchBark Foundation?
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Pet's Name
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Species
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Dog
Cat
Breed
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Age
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Sex
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Male
Female
Photo of Pet with Owner
THIS IS A REQUIREMENT FOR BIRCHBARK FINANCIAL ASSISTANCE. If you are unable to upload photo, please contact us at info@birchbarkfoundation.org or 831.471.7255.
Photo of Pet Only
Additional Photo of Pet
Spayed or Neutered
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Yes
No
What does this pet mean to you and/or your family?
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Are there other pets in the home? If so, please list their species, age, and spay/neuter status.
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Describe your pet's injury or illness. How did the injury occur?
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When did this injury/illness first occur?
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(mm/dd/yyyy)
Is your pet at the hospital now?
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Yes
No
Describe the circumstances that are keeping you from being able to afford your pet's treatment.
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BirchBark Foundation assistance can help with funds after your resources have been used - including Care Credit, retirement funds, savings, loans from friends and family.
Hospital Treating your Pet
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BirchBark can only fund pets that are being treated at one of our Veterinary Partner Hospitals.
select one
Adobe Animal Hospital
Aguajito Veterinary Hospital
Animal Cancer Center
Animal Hospital of Salinas
Animal Hospital of Soquel
Aptos-Creekside Pet Hospital
Ark Animal Hospital
Carmel Valley Veterinary Hospital
Companion Animal Hospital
Cottage Veterinary Care
Dentistry for Animals
King City Veterinary Hospital
Los Coches Animal Hospital
Nichols Veterinary Care
Ocean Animal Clinic
Pacific Santa Cruz Veterinary Hospital
Pawsitive Pet Mobile Vet
Purrfurably Cats
Scotts Valley Veterinary Clinic
Toro Park Animal Hospital
VCA All Pets Animal Hospital Salinas
VCA Animal Hospital of Santa Cruz
VCA Oceanveiw Animal Hospital
Westside Animal Hospital
Hospital Phone
*
Hospital email to be notified of application submission
*
The hospital will provide you with the appropriate email address to enter here. The hospital will NOT be notified of your submission without the correct email address entered here. Please check with the front desk of the hospital if you are unsure of what to enter.
Verify Email
*
Please read all of the following and check if you understand and agree:
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I agree that the information provided above is true to the best of my knowledge.
*
If approved, BirchBark provides funding for up to 50% of the bill and Veterinary Partners discount 25% from their services. The owner will have to use the entire amount of Care Credit towards the pet's treatment. The owner and hospital must come to a payment agreement for the client's portion of the bill.
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All animals that receive BirchBark funding must be spayed or neutered. If an animal is not spayed/neutered at the time funding is given, the owner will agree to have their animal sterilized within a set time frame determined by the treating veterinarian.
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If approved, I agree to allow BirchBark to film my success story within a month of treating my pet so that donors can learn about the successful outcome of my pet.
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I understand that BirchBark may ask other funding sources to assist in paying for the veterinary care needed and I hereby consent, in connection with my request for financial assistance from BirchBark, to BirchBark providing any and all financial, personal and credit information that I provide to BirchBark to other potential funding sources.