Please fill out all required fields before clicking the submit button. You will receive a red error message under the field requiring information before your application can be submitted.
*indicates a required field

Your Full Name*

Mailing Address*

City*

Zip Code*

Your Email*

Contact Telephone Number*

Your Pet's Name*

Your Pet's Gender*

Species/Type/Color of Your Pet*

Your Pet's Age*

Is your pet spayed/neutered?*
YesNo

Time You've Had Your Pet*

Veterinarian's Name*

Veterinarian's Telephone Number*

Veterinarian's Mailing Address*

Date of Last Vet Visit* (make selection from date picker on calendar)

Diagnosis or Describe Pet's Problems*

Estimated Cost of Treatments* (attach estimate from vet)

Proof of Identification*
(Driver’s license, State-issued ID card, Social Security card)

Total Family Annual Income
Attach proof of income (Social Security, disability records, unemployment pay stubs, 3 months payroll stubs, etc.)

How Many People in Your Household?*

Monthly Rent/House Payment:*

Reasons You Need Financial Assistance*

Please Upload Two Pictures of Your Pet*
Picture One

Picture Two

Please complete all requested information above. You can email additional information or requested files to: PAHS@paloaltohumane.org

By clicking "submit", I authorize my veterinarian/s to discuss my animal’s health records and care with Palo Alto Humane Society (PAHS). I also authorize PAHS, if funding is approved, to share my animal’s information and photo/s as PAHS sees fit. I attest that the information I provide is true and correct and I am applying for assistance because I am in financial need and would otherwise be unable to treat my animal. I release PAHS from any and all liability connected with any assistance I may receive.

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