Apply for Help

Looking for help?

To apply for financial assistance, please complete the following form:

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How are you applying?

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone

Horse's Name

Horse's Sex

Horse's Location/Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Horse's Age

What amount of financial assistance are you in need of

Describe why you are applying for financial assistance

Referrals/Consent

We require consent to discuss your horse's situation with a veterinarian.

Name of Veterinarian

First

Last

Address of Veterinarian

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Horse's / Name:

Email of Veterinarian

Phone of Veterinarian

By signing, I confirm that the above statements are true and that I recognize that I am personally responsible for any veterinarian, farrier, emergency board/feed, or deadstock removal expenses incurred by me in the care of my horse and not covered by MDHPIC.

Signature

Clear Signature

Date / Time

Date

Time

UPPER LIMITS FOR HORSE CARE COVERED BY MDHPIC:

The following are UPPER limits for horse care covered by MDHPIC. Each request for assistance is decided on a case-by-case basis. MDHPIC does not guarantee coverage for full amount of vet care or deadstock removal. The horse owner is responsible for any amounts owing in relation to the care of their horse. This is a one time offer per horse owner.

UPPER LIMITS/MAXIMUM AMOUNTS IF REQUEST FOR ASSISTANCE IS APPROVED.

Humane Euthanasia by a Veterinarian: $400
Deadstock Removal: $400
Gelding by a Veterinarian: $150
Dental Treatment by a Veterinarian: $150
Feed/Board in Emergency: $100
Farrier Care: $75