Keeping Pets Home Application

Requirements: Person(s) applying must be 60+ years of age and have a senior dog or cat 7 years of age or older. Person(s) applying must be on a fixed/limited income. Proof may be requested at any time. All applications must be approved by Lionel’s Legacy before services are rendered. Financial assistance for dental care is granted directly to your pet’s veterinarian, we do not reimburse individuals directly. Support is provided solely based on available funding for services. We do not provide emergency funding, requests may take up to 2 weeks to process. Requests must be made annually and may not exceed $500 per family annually.

Name(Required)

First Last

Address(Required)

Street Address City State Zip Code Country

Phone

Age of individual seeking assistance

Emergency Contact Name

First Last

Emergency Contact Phone

Reference Name

First Last

Reference Phone

Dog Information

Dog's Name

Dog's Age

Pictures

Please submit 3 high quality pictures of the pet(s) you are seeking financial assistance for.

Max. file size: 256 MB.

Sex

Male

Female

Altered?

Yes

Date of Last Vaccines/Exam

Date of Last Bloodwork/Urinalysis

Has a Dental ever been performed?

Yes

Current Medications and Known Medical Conditions

Vet's Name

Vet's Phone

Vet's Fax

Vet's Email

Vet's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Request Information

Reason for Requesting Support

Briefly explain why you’re requesting financial assistance for dental care for your pet.