image image

 

PLEASE READ

WestieMed's desire is to help a greater number of Westies in need during these difficult economic times, therefore, we find it necessary to limit funding for any one individual applicant or rescue group to a maximum of $2,000 and restrict funding for the same person or group to no more than once every three (3) months. Per our Funding Guidelines, each case will be assessed on an individual basis.

WestieMed Application Form:

Applying for financial assistance from WESTIEMED is a simple process, but we regret that not all applicants, dogs, or medical conditions will meet our funding criteria. To determine whether your Westie is eligible for financial assistance through WESTIEMED, please read our

Once you've confirmed that your Westie meets all of our requirements, the next step is to fill out this application. At the end of this application, you will be asked to confirm that you have read all of the above and understand that if funding is approved, you agree to abide by all rules and contingencies set forth by the organization. Please ensure that you have read those items prior to filling out this application.

IF YOUR DOG IS NOT A WESTIE OR IF THIS WESTIE IS YOUR PET,

DO NOT complete this application. WESTIEMED is NOT able to consider applications for assistance for non-Westies or established pet Westies (i.e. dogs who are not in a rescue situation or who have not recently been rescued). If you have any questions about this, please see our Funding Guidelines, Item number 8.

If this Westie is your pet and you need assistance, please visit these websites: HSUS listing of national and state organizations that help pet owners

Instructions:

Please fill out the Application Form below completely. Incomplete applications will not be considered.  Failure to supply the requested information (i.e., Westie's photo, veterinary receipts or invoices, etc.) will result in a delay and could result in a denial of your request. After submitting your application form, you will receive a response within 48 hours.

If you have any questions or problems submitting this form, please contact aid@westiemed.org or call the toll-free WestieMed Message Center at 1-877-853-9469.

If this is a life or death emergency and you need a response from us within 24 hours, then YOU need to make sure we are provided with the following:

  1. The vet must be available to speak with a WESTIEMED representative.
  2. You must get a picture of the dog to us within 24 hours. You can e-mail a picture to aid@westiemed.org. If you are not able to e-mail one, but choose instead to send one by overnight mail, the address is:
    WESTIEMED, Inc. 342 Black Gold Dr. Harrison, OH 45030

    If you do not have a camera, you may want to purchase an inexpensive disposable camera, take photos of the dog requiring assistance, have the film developed at a one-hour or overnight photo shop, and forward the photos to WestieMed. Some photo shops offer services where they will put the photos on a disk for you.

  3. In the medical section of the application, please give us as much detail as you can on the nature of the treatment needed and information on what treatment has already been given.

Contact Information:
Contact Name:
Address:
City:
State:
Zipcode:
Country:
Telephone:
E-mail:
Additional Contact or other Information

Dog Information:
If you are applying on behalf of a rescue group or other organization, please name the group or organization:
Name of Rescue Dog:
Date Dog Was Rescued:
Has Dog Been Adopted?: Yes No
Date Dog Was Adopted:
Sex of Dog: Male Female
Approximate age:
Approximate weight:
Has the dog been spayed/neutered? Yes Not yet
How will you be sending the photo? e-mail (preferred) overnight mail priority mail regular mail
If applicable, list any identification tags/tattoos or microchips:
What attempts have been made to contact the owner of the dog?:
Has the dog's breeder (if known) been contacted?
How did you find this rescue dog?
Do you know anything about this dog's background?
Has this dog shown any animal- or human-directed hostility?
Would you be willing to foster this dog? If yes, for how long?

Medical Information:
Is this a life or death emergency? Yes No
Please provide a full description of the rescue dog's illness or injury:
Dog's current location is: Veterinarian Clinic Shelter Private Home Other
Name, address, and phone number of treating Veterinarian:
Describe the dog's medical diagnosis/prognosis:
Describe the recommended course of treatment:
What is the estimated cost of treatment?
Was a rescue discount requested? Yes No
If yes, will a discount be granted? Yes No

Funding Information:
How did you find out about WestieMed?
Did you contact any local Westie Breed and/or Rescue organization? Contacted Not contacted N/A If yes, please summarize their response to your situation:
Have you contacted any other organizations regarding this Westie or Westie-Mix? If yes, please supply the contact person's name and contact information, and summarize their response to your situation.
How much have you already spent on this dog's medical treatment and care?
How much are you or your rescue group able to contribute toward this bill?
Please specify the amount you are requesting from WESTIEMED:
NOTE: Please enter all funds in US Dollars. To convert funds, use the Universal Currency Converter.
Is the amount requested from WESTIEMED different from the estimated cost of treatment? Yes No N/A If yes, please explain.
I agree to abide by all rules and contingencies set forth by WestieMed. Yes   No

image
image image