Request Form

Cooper’s Legacy Foundation is very sorry to hear that your pet is ill! This preliminary application is designed to help determine whether or not your family fulfills the initial criteria established to assist with the treatment of your pet. Please answer as thoroughly as possible. We may have follow-up questions based on your answers and will contact you if we need more information. Treatment is never guaranteed. We reserve the right to refuse, alter, limit, or rescind offer to cover expenses if circumstances change or new information is uncovered. Unfortunately we do not have the technological capability to allow a partially completed electronic preliminary application to be saved and returned to at a later time/date. The uploadable preliminary application must be completed entirely and submitted before leaving this page or the information will be lost. Therefore we suggest you review all the questions and assemble any documentation you may need prior to starting the application process so that the information is readily available to you as you complete the application.

* Indicates required field

Your Name *

First

Last

Your Phone Number *

Your Email *

Your Street Address 1 *

Your Street Address 2 *

Your City *

Your State *

Your Zip Code *

Veterinarian's Name *

First

Last

Veterinarian's Phone Number *

Street Address Line 1 *

Street Address Line 2 *

City *

Select One *

ZIP Code *

Pet Name *

Pet Type *

Pet Breed (best guess) *

Age *

Sex *

How long has the pet been a member of the family *

Is your pet spayed / neutered? *

Is your pet licensed in the city / country? *

If no to the previous question please say why not. *

Is your pet up to date on its vaccinations? *

If no to the previous question please say why not. *

What is your current veterinarian's diagnosis and recommended treatment? *

Is this condition due to injury? *

If yes to the previous question please explain how the injury happened. *

Did you know about your pet's condition when you acquired it? *

Estimated cost of treatment *

Long term prognosis (Years of life anticipated post-treatment barring unforseen circumstances) *

Total cost of diagnosis / treatment up to this point *

How much can you afford towards further diagnosis / treatment? *

Have you been offered charitable or credit assistance through another organization? *

If yes to the previous question please say how much and by who. *

Will your pet remain in your home after treatment? *

Can you provide additional financial documentation if requested? (Such as, but not limited to, tax forms, pay stubs, W2, public assistance documentation) *

Tell us your story! (Give us any additional information you feel will help us to understand your situation) *

Submit

Preliminary Application