Direct Assistance

Request for Assistance

Referral Agencies Only

Please fill out the form below for written pre-approval prior to committing funds.

Agency Name*:
Your Name*:
Phone*:
Fax:
E-mail address*:
Assistance from:	Dental Fund, $150 maximum Prescription Fund, $150 maximum Medical Fund
Amount requested*:
Reason for request*:
Explain financial need*:
Name of Patient*:
Age*:
Has patient received help from AVMF this calendar year?*:	Yes No
*required fields