FAMILY ASSISTANCE APPLICATION

Tell us about your family, your pet, and the care they need.

Use this form to request assistance when a medically reasonable veterinary diagnostic or treatment option exists, but cost has become a barrier for your family.

Before you begin

Completing this form does not guarantee assistance. The Foundation reviews financial need, veterinary information, available funding, medical reasonableness and the animal's circumstances.

Do not fill this out if you are human:

ABOUT YOU

Family & contact information

Tell us who is requesting assistance and how we can reach you.

First nameLast name

Street address

CityStateZIP code

Email addressPhone number

Your relationship to the animal

YOUR PET

Tell us about the animal you love.

We want to know who they are—not only what is happening medically.

Pet's nameSpecies

BreedAge

SexSpayed / neutered?

How long has your pet been part of your family? Tell us a little about your pet and what they mean to your family.

VETERINARY SITUATION

What is happening medically?

Please share what your veterinary team knows today and what they recommend next.

Diagnosis or suspected diagnosis Current symptoms or condition Recommended diagnostic, procedure, treatment or next step

Estimated total costHow urgent is the care?

Has treatment or diagnostic work already begun?

VETERINARY PROVIDER

Who is providing the care?

Veterinary verification will be an important part of our review process.

Veterinary clinic / hospital Veterinarian or specialist name

Clinic phoneClinic email

Clinic address I authorize The Nala Legacy Foundation to contact the veterinary provider listed above to verify medical information, recommendations and estimated costs.

ASSISTANCE REQUESTED

Help us understand the financial need.

We want enough information to make responsible charitable decisions without making families feel judged for asking for help.

Amount requested from the FoundationAmount your family can contribute

Do you have pet insurance? Have you received or applied for other financial assistance for this care?

Household sizeApproximate annual household income

Please explain the circumstances creating the financial hardship.

SUPPORTING DOCUMENTS

We may request documents after submission.

Please do not send sensitive financial documents through this form.

Veterinary estimateWe may request a written estimate directly from you or the veterinary provider.

Relevant veterinary recordsWe may request records needed to verify the diagnosis, suspected diagnosis or recommended care.

Additional verificationIf additional documentation is needed, the Foundation will contact you with instructions.

WHY THIS FOUNDATION EXISTS

Nala's family had the opportunity to pursue every reasonable option available to her.

Tell us what having another option would mean for you and your family.

CERTIFICATION

Authorization & acknowledgment

I certify that the information provided in this application is true and complete to the best of my knowledge. I understand that submitting an application does not guarantee financial assistance or approval of any specific treatment. I understand that approved assistance is intended to be paid directly toward eligible veterinary care rather than issued as unrestricted cash assistance. I understand that The Nala Legacy Foundation does not provide veterinary advice and that medical decisions remain between my family and our veterinary professionals.

Applicant signature (type full legal name)Date

Submitting this application does not guarantee funding. The Foundation may contact you and your veterinary provider to verify information and determine eligibility. The Foundation does not provide veterinary advice, and medical decisions remain between you and your veterinary professionals.