5021 N. State Rd. 26
Janesville, WI 53546
608-868-1761
Quarters for Critters
Helping animals one quarter at a time
**To better serve your companion it is necessary to know his/her medical history. It is required along with this completed form to qualify for assistance.**
Financial Assistance Application
Name:________________________________ Phone:____________________________
Address:__________________________ City:________________ State/Zip:__________
Assistance is based on financial need. Please circle any/all that apply:
Food stamps Medicaid SSI AFDC WIC Disability Retired Unemployed Multiple Pets
How many adults live in household?____________________
How many children live in household?__________________
Applicant employment information:
Current employer_________________________ Number of years employed_________
Monthly income__________________________
Previous employer_________________________ Years employed__________________
Spouse employment information:
Current employer________________________ Number of years employed__________
Monthly income_________________________
Total monthly expenses:
Auto payment_______________________ Credit Cards__________________________
Utilities____________________________ Loan Payments________________________
Misc.___________________________________________________________________
Assistance is requested for the following animal
Name:_______________________ Age:_______
Circle to describe pet: Female / Male Spayed / Neutered
Is the animal a cat, dog, or horse?
Has your female given birth? Yes or No? How many litters?_________
Is she in heat or pregnant at this time? Yes or No?
List additional pets in household.
1. Name____________________ Species_______ Breed________________ Age_______
Spayed/Neutered?_______ Number of years owned_______
2. Name____________________ Species_______ Breed________________ Age_______
Spayed/Neutered?_______ Number of years owned_______
3. Name____________________ Species_______ Breed________________ Age_______
Spayed/Neutered?_______ Number of years owned_______
Please list your regular Veterinary Clinic: _____________________________________
How many years at above clinic?____________________________
Previous Veterinary Clinic__________________________ Years there: _____________
Please describe/explain why you need our help:
This page is to be completed by attending veterinarian.
○ Urgent (emergency) case
○ Non-urgent (specialty) case
Clinical findings/Diagnosis:
Short/long term prognosis:
Total cost for procedure(s) $______________
(Please attach an itemized estimate of invoice)
Date: ______________
Veterinarian Signature:_____________________________________
Office Use:
To be considered for funds, the case must meet the following criteria:
○Yes ○No Program has available funds.
○Yes ○No Client has applied for third-party payment plan.
○Yes ○No Client has pre-paid his or her portion of the estimate.
○Yes ○No With immediate care, the patient will likely experience a significant, long-term benefit.
1st Contact Date_____________
Client’s financial responsibility__________________________________
QFC financial responsibility_____________________________________
Payment date ___________ Treatment/Surgery completed date _________