The fund donated and raised by members of the Muffin Diabetic Pet Group are held in trust and are used to assist the companion animals of those in financial difficulties. The applicant is responsible to the medical provider to pay for all those charges which Muffin cannot or will not cover. 

What Muffin will not cover: 

• Routine care such as spay/neuter, vaccines, heartworm preventative, routine office visits, etc. 
• Outstanding unpaid bills 
• Reimbursement of prior vet bills 

You must provide a written estimate from your pet's veterianarian before approval is given. In addition, it is your responsibility to advise your veterinarian that invoices must be received no later than 30 days after treatment. 

As a general rule, funds are disbursed only to a pharmacy or the veterinarian whose name is on the application. If funding has been approved for your pet we can only pay the vet if there is a "balance due" shown on the invoice when we receive it. If you have put the charges on your credit card, written a post dated check or used other means of payment we cannot send funds to the vet so he/she can reimburse you. 

It is your responsibility to make and keep appointments with your veterianarian. We will not cover fees for late or missed appointments. 

Prior to approval, you mjust obtain a written estimate from your veterinarian. This must be on the veterinarian's letterhead and must include the following: 
 

• your full name 
• your pets name 
• diagnosis 
• prognosis 
• complete breakdown of costs, 
• the urgency of your pets condition and 
• will your veterinarian accept third party payment?
• A written estimate from the attending veterinarian is always required before the application can be completely reviewed. 

If you have read and understand the above, please complete the following questionnaire and e-mail it to muffin@petdiabetes.net 

Application for Financial Aid from the Muffin Pet Diabetes Support Group. 
Please provide as much of the information requested as possible. All information will be kept strictly confidential. Upon completion, print a copy for yourself and e-mail the form to the Muffin Committee 
 

• Today's date: (mm/dd/yy)

• I have read all of the information and Muffin regulations pertaining to financial aid prior to submitting this application and am in agreement. | YES /No - if you have answered no to this question, do not proceed

• I understand and agree that Muffin is to be used only as a last resort for funding  - yes/no

• How did you hear about the Muffin Diabetic Pet Group? 

PERSONAL DATA

• Your full name: 
• Address: 
• Home Phone: _________ Work Phone: ________ Fax: ________ E-Mail: ____________ retype your E-Mail________
• Are you employed? Yes____ No____ 
• If you are not employed, what is your source of income? 
• How many dependents do you have, including yourself? 
• What is your total monthly income? 
• Who makes the final decisions with regards to your pet? 
• Proof of income is required.  What proof of income will you be providing?
• If you have credit cards, how much credit do you have available?

VET INFORMATION / PHARMACY INFORMATION

Veterinarian:

• Name: 
• Address: 
• Telephone: ___________ Fax______________ E-Mail ____________ 

• Name: 
• Address: 

Telephone: ___________ Fax______________ E-Mail ____________ 

PET INFORMATION 

• What kind of pet 
• Name of Pet 
• Age of Pet 
• Has your pet been spayed or neutered? 
• When was your pet diagnosed with diabetes? 
• What type of insulin? 
• What is the dosage? 
• Is your pet regulated? Yes____ No_____ 
• Do you do home blood glucose testing? Yes____ No____ 
• If no, why not? 
• Does your pet have other health problems? 
• If so, what are they? 

ADDITIONAL INFORMATION ABOUT YOUR PET'S DIABETES:

• Estimated monthly costs:  We  will need to know what your average monthly expenses are to care for your diabetic pet. Please enter the dollar amounts in the spaces below the items and if you are unsure, enter NA

• What is the total amount you need monthly from a sponsor to care for your pet's diabetes?

• What amount will you contribute? 

• Visits to your veterinarian are not as costs may vary. If your application is approved you will need to notify us  when you need a vet visit if we are to cover the cost of this. You must always have an itemized written estimate from your vet faxed to the board prior to the visit so they may determine whether or not the funds are available.

MORE VETERINARIAN INFORMATION

• Have you sent us a written estimate from vet? Yes___ No_____ 
• If not, when will you be sending this? ______________ (Please understand that we cannot proceed with your application until we have this estimate) 
• If you do not have an estimate, why not 
• Have you advised your veterinarian Muffin may be providing financial assistance for your pet? 
• If your vet will not agree to our payment terms, assistance cannot be provided.   Have you confirmed with your vet that they will work with our  payment policy?  Yes / No
• What is the total cost of the current procedure (an estimate is satisfactory) 
• What portion of your pet's care can you pay for yourself? 
• What portion of your pet's care are you applying for from the Muffin Pet Diabetes Support Group? 
• Do you have an appointment with your pet's veterianarian regarding the current problem? 
• If so, when is this appointment? 
• From what other sources have you requested assistance? 
• What response did you receive? 
• Have you done any fundraising on your own to get veterinary care for your pet? 
• If so, what was this? 
• Have you attempted to make payment arrangements with your veterianarian? 
• What was the response? 
• Do you have an outstanding unpaid account with your veterinarian? Yes___ No___ 
• Do you understand that the Muffin Diabetic Pets Fund will not accept responsiblity for this unpaid account?   Yes ___ No____ 
• Will you be able to repay Muffin for any funds paid on your pet's behalf? Yes ___ no_____ I will try ______ 
• Due to the large number of applications received for sponsors there could be a waiting period before your pet receives assistance.  Do you understand that immediate help may not be available?          Yes / No

PETS IN NEED PAGE 

• If your pet is approved for financial assistance from Muffin, they will have their own page on the Muffin home site. We will require a photograph. Will you be sending it by: e-mail ___ or post _____? 

In the space below please explain to Muffin donors why they should choose your pet to sponsor or make a donation for.  This information will be on your pet's page.  Please tell our donors why you feel your pet is special and the impact it has on your life.  This information will be exactly what will be on your pet's page.  You may use as many or as few  words as you like.  The more information donors have about your pet, the more likely they will want to help.