Emergency Outreach Voucher
EMERGENCY OUTREACH VOUCHER
Humane Society of the Ozarks
First Name
*
Last Name
*
Address
*
City
*
State
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AR
MO
OK
Zip Code
*
E-mail Address
*
Phone
*
Pet's Name
*
Gender
*
Male
Female
Species
*
Dog
Cat
Date of last vaccines
*
What's wrong with animal? (Provide as much information as possible.)
*
Choose a Vet Clinic
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Bella Vista - Village Animal Hospital
Bentonville - Oakwood Pet Hospital
Farmington - Country Vet Service
Fayetteville - Best Friends Animal Hospital
Fayetteville - Cornerstone Animal Hospital
Fayetteville - Gulley Park Pet Clinic
Fayetteville - Stanton Animal Hospital
Huntsville - Huntsville Vet Clinic
Lincoln - Lincoln Vet Clinic
Lowell - Lowell Vet Clinic
Pea Ridge - Pea Ridge Vet Clinic
Rogers - Cat Clinic of NWA
Rogers - New Hope Animal Clinic
Springdale - Crossover Vet Clinic
Springdale - Springdale Animal Hospital
Springdale - St. Francis Animal Hospital
Springdale - Southwest Pet Hospital
Siloam Springs - Siloam Springs Vet Clinic
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The above clinic should be a vet clinic you have already spoken with or currently use. If not, please verify they are accepting our vouchers and new patients!
*
If you have it available, please take picture and upload proof of low income. This can be a paystub, social security award letter, disability letter, food stamps, etc. If you don't upload proof thru this form, you will be required to show proof before approval.
Attach proof of income
*
*
Gudelines:
HSO:
HSO will ensure that only emergency requests will be approved. HSO will also require documentation that the individual is considered low income before being approved for a voucher. HSO will ensure that only 1 pet per address per year will be able to receive a voucher.
Vet:
Vet agrees to waive their basic exam fee for individual. Vet also agrees that the voucher amount will be used for treatment costs and not for preventative uses. Vets may use their own discretion and deny any voucher they do not deem a true emergency.
Individual:
The client
agrees to pay any amount over the FUNDS provided by HSO
. Client also agrees to ensure that the use of this voucher will be only for true emergencies. Client will provide HSO with accurate paperwork to prove they are considered low income for the voucher to be approved.
E-Signature (type full name)
*
For Office Use Only:
HSO Rep ESignature: Chase Jackson, President
Please return this voucher with invoices attached to hsoadmin@hsozarks.com or mail to: 11204 Nile Ave Oklahoma City, OK 73114 (Temp Mailing Address).