Welfare Assistance

RSPCA Llys Nini Voucher Request Form

RSPCA Llys Nini, as part of its objectives, is to provide support for animal welfare. We can offer some support for animals whose owners cannot afford medical care for their pets and who are on low incomes.
THIS FORM IS TO BE COMPLETED BY THE VET IN LIAISON WITH THE CLIENT
Clients Details
Name *

First Name Last Name

Address *

Are any of your pets insured? *

Yes No
If yes, please tell us the name of your insurer
Are you the legal owner of pet(s) named on this application? *

Yes No
Have you applied for any other vouchers in the past 12 months for any of your animals? *

Yes No
If yes, have you applied for a voucher for this animal in past 12 months? *

Yes No

Nature of complaint of animal *
Please provide a summary of the nature of the health issue
Estimated cost of treatment *
Branch contribution (50% of treatment to a maximum of £75.00)

Surgery Address *

To be completed by the recipient of this voucher:

Application to receive support for veterinary treatment at RSPCA Llys Nini:
Every application will be looked at on a case by case basis and will not be automatically funded. I declare that I am not in a position to pay the full fees of the VeterinarySurgeon. (Please note that proof of benefits may be required.)

All personal information supplied by you on this application form will only be processed by the RSPCA Cardiff to Swansea branch whose privacy policy is available and published at: www.rspca-llysnini.org.uk/privacy-notice.php
Clients e-Signature *
Type name here
Date *

- Day - Month Year
Date
Should be Empty:

RSPCA Llys Nini Voucher Request Form