Muffin Diabetic Pet
Group Relief Fund
The funds donated and raised 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.
The applicant must:
. be in financial need and be unable
to pay the cost for treatment
contribute financially to some degree and if need
be, apply for Citi
Health, Care Credit
or similiar instituion and either is denied or approved for limited funding
must be appreciative of the financial assistance
if they have been approved for a assistance
agree to repay the Fund if their financial condition
changes in the future
provide Muffin with updates and photos. Applicant
will be required to send an email update to Muffin at least once per week.
We feel our applicants should be willing to be an active participant in
have made and continue to make an effort to
find other sources of funding - suggestions
What Muffin will not cover:
If your application is approved, you will be
notified within 48 hours by e-mail. Within 2 working days after that, you
must complete the application in its entirety or approval will be withdrawn.
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
It is your responsibility to make and keep
appointments with your veterianarian. We will not cover fees for late or
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
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 email@example.com
|Please copy & paste the following questionnaire into your word
processing program (such as wordpad) and when completed, e-mail to the
Committee with documentation attached or mail to Muffin Diabetic Pets
Association, c/o 2017 - 7th Avenue N.W., Calgary, Alberta, T2N 0Z7.
If you would like a copy e-mailed to you in text or .pdf format, let us
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
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
VET INFORMATION / PHARMACY INFORMATION
Your full name:
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
How many dependents do you have, including
What is the total monthly income of your household?
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?
Telephone: ___________ Fax______________ E-Mail
Telephone: ___________ Fax______________
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____
If no, why not?
Does your pet have other health problems?
If so, what are they?
ADDITIONAL INFORMATION ABOUT YOUR
Insulin / Syringes / Meter strips / lancets / ketostix
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?
MORE VETERINARIAN INFORMATION
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.
Have you sent us a written estimate from vet?
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
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
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.