// WAG Application

Make a Difference; Make A Wag.

Make a wag provides financial reimbursement to veterinarians/clinics for their financially struggling elderly clients (65 years of age or older) whose pet (companions) need unexpected/emergency medical care. To receive funds:

Only licensed veterinarians/clinics can apply for funds.

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Clients must be the registered pet owner, 65 years of age or older, struggling financially whose pet/companions need unexpected/emergency medical care.

A veterinarian must complete the application and submit all required documentation to be considered for reimbursement of expenses already incurred by their client.

Due to funding demands, the maximum amount allotted for any one pet/companion is (up to) $2500.

Veterinarian reimbursement is limited to $2500 per annual year, but that reimbursement can be used for multiple client/pets.

Make A Wag – Jeffrey Sutarik, DVM Charitable Fund dollars will send reimbursements to the veterinarian/clinic/hospital completing the application for reimbursement. No dollars will be distributed to individual clients/pet owners.

Date of Request*

Veterinary Hospital Name*

Veterinarian*

Veterinarian Contact Phone*

Email*

Owner Name*

Describe why this client is worthy of reimbursement due to financial hardship*

Pet Name*

Species (dog, cat)*

Breed*

Age*

Neutered*

Yes
No
Unknown

Time the pet has been with owner*

Pets information and veterinary care

Describe the nature of the condition/diagnosis/treatment provided to the pet*

REQUESTED REIMBURSEMENT*

(Attach itemized veterinary bill for the care provided)

I have informed the owner of the criteria requirements for consideration for reimbursement.

Be advised that Make A Wag attempts to assist as many financially struggling elderly pet owners as possible. Therefore, financial assistance is limited to a total of $2500/per client. Veterinarians can apply for up to $2500 per calendar year. Clinics/Hospitals with multiple veterinarians can apply multiple times, but each veterinarian is limited to $2500 per calendar year.

This financial assistance reimbursement will be provided to the veterinarian/hospital after the application form is completed and includes the itemized veterinarian bill. Funds may only be used for the client named on the application. This reimbursement is a gift from the Make A Wag – Jeffrey Sutarik, DVM Charitable Fund with disbursement through the Veterinary Care Foundation.

Your time and dedication to maintaining this companionship of the pet with its’ owner is in-line with the mission of the foundation and honoring Dr. Jeffrey Sutarik’s contribution to the profession and the public.

VETERINARIAN ELECTRONIC SIGNATURE*

By signing this application, you attest that all information above is accurate and that you agree to the terms presented by Make A Wag – Jeffrey Sutarik, DVM Charitable Fund for Elderly Pet Care.

Reimbursement checks will be sent to you at the address provided from the Veterinary Care Foundation for Make A Wag.