Canine Care Tampa Bay Application

Name:

Address:

Phone number:

Email address:

Number of adults in household:

Number of children in household:

Pets in household (please include all pets)

Type of Pet
(Include breed if Dog) / Pet’s Name / Male or Female / Age of Pet / Date of Last Vet Visit

Name of current veterinary clinic:

Phone number of current veterinary clinic:

Are all of your pets spayed and / or neutered?

If not, why?

Please note: Canine Care only assists pets that are spayed or neutered. We are happy to refer you to a low cost spay / neuter clinic if needed.

Does your pet have any serious illnesses? If yes, what have they been diagnosed with?

Is your pet currently experiencing any minor ailments (for example itchy skin or hotspots, ear/eye infections, etc)? If yes, please describe.

Is your pet currently on flea and tick and heartworm preventatives?

How long has your pet been in your family?

How did your pet come to live with your family (for example, adopted from a shelter, bought from a breeder or pet store, came to you as a stray)?

Is your dog(s) currently licensed with the State of Florida?

Are the adults in your household currently employed?

If yes, name of employer?

If no, how long have you or other wage earners in your household been out of work?

What is your annual household income?

Please explain why you are requesting assistance and how this assistance would help your pet:

Without financial assistance to help pay for your dog(s) basic veterinary bill, what would you do?

Is there anything else you would like us to know for qualification purposes?

Please note: The intent of Canine Care’s program is to assist with the wellness health care of pets living in families going through tough financial times. Canine Care assists approved applicants with a one-time visit (follow-up visits are not covered unless previously approved by a Canine Care representative). Canine Care is not in a position to assist with major ailments. Wishing you and your pet continued health and happiness. Thank you for reaching out to us.