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Request Assistance

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Name *

First

Last

Email *

Phone Number

Home Address

Pet's Name

Pet Species

Dog
Cat
Other

Please Describe the Concern your Pet is experiencing. PLease include how significant the concern is, the symptoms, how long its been going and any past Vet care.

Do You Have a Vet?

Yes
No

Vet's Business Name (Organization)

Vet Phone Number

Vet Address

Are you aware you need to provide for transportation to and from the Vet to address the concern?

Yes
No

Are you aware that LRR-Outreach will only pay a portion of the Vet bill and you are responsible for the reminder?

Yes
No