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Application for Medical Assistance

PLEASE READ GUIDELINES, INSTRUCTIONS AND REQUIREMENTS BEFORE PROCEEDING! CLICK HERE
We do our very best to assist as many people as possible. More and more animal guardians are unable to afford veterinary services, and as a result we are being inundated with more and more requests for help. So do not expect an immediate response. It may take up to five days to respond to some requests. Because of the flood of requests being received and the limited amount of funds available, we cannot guarantee that we will be able to reply to your request at all. We do not review applications over the weekend. If you do not hear back within approximately five days you may leave a message at 818.752-6725. We cannot guarantee that all messages will be returned. We do our best. Do not call the general number of Actors and Others, as you will be referred to the 818.752.6725 medical number.

AGAIN, IF YOUR PET IS IN NEED OF IMMEDIATE CARE WHERE ANY DELAY WILL PUT THE ANIMAL AT RISK, IT IS YOUR RESPONSIBILITY AND DUTY TO GET THE ANIMAL TREATMENT. AND PLEASE BE AWARE THAT THERE IS NO GUARANTEE WE WILL BE ABLE TO PROVIDE YOU WITH ANY FINANCIAL ASSISTANCE.
All fields marked as *required must be completed for the application to be considered. Please be sure to double-check that your telephone numbers are correct. And remember, we cannot provide assistance if your pet is not spayed or neutered or can be sterilized at the time of treatment. We do not cover the cost of the entire procedure. We cannot provide assistance if you cannot pay anything toward the treatment. We cannot provide assistance if your veterinarian is unwilling to bill us for the services.

After you hit the "Send It" button, a page will immediately pop up saying "Thank You" with a picture of a smiling Collie. You will then receive a confirmation email with a copy of your application. If you leave any of the questions blank, a computer generated page will pop up saying that "You left the [question] blank." You must go back and complete the entire application.
 
* These fields must be completed for the application to be considered.
I have read and understand the guidelines, instructions and requirements.
 
*First Name Owner/Guardian:
*Last Name Owner/Guardian:  
*Address:   *City:
*Zip Code:  
*Day Phone: *Alternative Phone:
*Email Address:
*Confirm Email Address (re-enter):
If someone other than the owner/guardian is assisting in the completion of this application, please provide your contact information.
First Name Contact: Last Name Contact:
Address of Contact:   City:
Zip Code:  
Day Phone of Contact: Alternative Phone of Contact:
Email Address of Contact:
*Have you received help from Actors and Others in the last calendar year?:
Yes or No?
 
*How did you hear about us?
 
*Are you seeking help for your own pet?
Yes or No?
 
*Pet's Name:
 
*Species - Dog, Cat, Rabbit, Other:
 
*Breed *Sex of Pet *Age
Male or Female
 
*Is your pet spayed or neutered?
Yes or No?
 
*If not, will you agree to sterilize your pet at the time of treatment if possible?
Yes or No?
 
*Describe your financial hardship:
 
*What is your household annual income? (The combined income of everyone living in your home and contributing to your household expenses).
 
*Describe the animal's injury/illness, how long the animal has
been sick and cause of any injury:
 
*What is the medical finding as to what is wrong with your pet?:
 
*What are the medical services needed?:
 
*Will such services cure your pet?:
 
*If not, why and what other services will be needed?:
 
*What is the cost of treatment?:
 
*How much are you able to pay toward the cost?:
 
*List any donations you have received from other organizations
and the amount of the donation:
 
*Name of Veterinarian/Clinic
*Address:   *City:
*Zip Code:  
*Phone: Fax:
Contact Name:
 
*Is the veterinarian/clinic willing to bill Actors and Others?
Yes or No?
 
*If Actors and Others provides financial assistance, will you send in photographs and a description of help provided for use by Actors and Others in promoting this program?
Yes or No?
 
By submitting this application you declare that you have read the guidelines and understand the requirements to receive assistance.
 
Remember: these fields * must be completed for the application to be considered.
 
Privacy Policy: Actors and Others for Animals respects your privacy, and will never sell, loan, lease, give or exchange your information. A Non-Discrimination Policy is on File.
 
We Care! Actors and Others for Animals
Actors and Others for Animals • 11523 Burbank Blvd. • North Hollywood, CA 91601 • (818) 755-6045 or (818) 755-6323 • Fax (818) 755-6048 • Email
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Privacy Policy: Actors and Others for Animals respects your privacy, and will never sell, loan, lease, give or exchange your information. A Non-Discrimination Policy is on File.