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Online Application
Pet Owners Full Name
Contact Number
Email
Address (include Suburb, Postcode & State)
Employment Status
*
Full Time
Part Time
Casual
Not Working
Retired/Pensioner
Disability Allowance
Other
Pets Name
Approx Age
Type & Breed of Pet (eg: Cat, Persian)
Gender
*
Male Unsterlisied
Male Sterilised
Female Unsterlised
Female Sterilised
Unsure
Other
How is your pet visually identified?
*
Collar only
Collar & ID tag
Collar & Council Registration tag
Collar & ID tag & Council Registration tag
Does not wear a collar
Is Your Pet Microchipped?
*
Yes
No
Unsure
Is Your Pet Council Registered?
*
Yes
No
Unsure
Do you breed from this pet?
*
Yes, I am a registered breeder
Yes, I am an unregistered breeder
Yes, it was an unplanned event
No, I have taken measures to prevent this
No, but I have not yet taken any actions to prevent it
I do not believe in sterilising pets
I would like my pet to be sterlisied
Briefly explain to us why your pet needs urgent medical treatment (If undiagnosed, please tell us the symptoms):
Which Vet Clinic/s have you consulted with? (Clinic Name & Phone number)
If you have seen a Vet, what was their diagnosis and suggested treatment plan?
What dollar amount have you been quoted for treatment?
Do you have Pet Insurance? (If yes, with which company?)
Are you open to using an alternative Veterinary Clinic?
PVBA are a charity so can only assist when all other funding options have been exhausted. Please tick which you have already explored:
*
Asked Friends and Family for Financial Help
Asked the Vet for a Payment Plan
Applied to Vet Pay (www.vetpay.com.au)
Sold Personal Assets You Own
Crowd Funding
Other
We will ask for documentation as proof that you have explored lending options. Please have these ready should we contact you. Do you have this ready to go?
PVBA require images and updates of your pet in order to create fundraisers and share case progress with our members. Are you able to provide quality, clear photos and written updates should we take your case on?
*
Yes I can provide photos of my pet immediately
Yes I will, but I need time to take current photos
I would like to, but I will need some help to do this
I do not have any available photos of my pet
Due to privacy reasons TBA I am unable to provide this
I agree to let the vet clinic provide images direct to PVBA of my pet in care
I understand that PVBA is a charitable organisation who is in no way responsible for the outcome of my pet’s veterinary treatments. I understand that PVBA will only approve treatment that is in the Pets best interest and not partake in treatments which will only prolong suffering. I agree that all supplied images become PVBA property. I undertake to support and regularly donate to PVBA charity.
*
Yes, I agree to These Terms
No, I Do Not Agree to These Terms
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