Dental Grant Application - Connecticut Greyhound Adoption

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Contact Information

Primary Owner's Name *

Co-owner's Name

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Phone

Greyhound’s Information

Dog's Name *

Dog's Date of Birth *

Gender *

Which organization did you adopt from? *

CGA
Other

Medical Information

Veterinarian's name and phone number: *

Date considered your

Is your greyhound current with all vaccinations? *

Yes
No
Other

Date of last routine (wellness) visit with your vet: *

Previous Dental Work: Has this dog had cleanings or extractions since adoption? *

List any previous cleanings or extractions and their approximate dates: *

Has your vet recommended specific dental health procedures? *

What has been recommended? *

Have you requested or been provided with an estimate of the costs of recommended procedures? *

Yes
No
Other

Please upload the estimate: *

Drag & Drop Files, Choose Files to Upload You can upload up to 2 files.

For dental procedures not requiring extractions, have you considered contacting someone trained in providing non-anesthesia procedures? *

List any other medical conditions or concerns:

Financial Consideration

Please note that any information that you provide CGA in connection with this grant application will be kept confidential. Due to limited available funding, this grant can support a limited number of needs-based applications. All submissions will be reviewed carefully to determine eligibility. The maximum amount of any grant is $500.

Please describe any financial hardships that make this grant necessary. *

If you are NOT approved for this grant, will you be able to cover the costs of all or a portion of the recommended procedures? *

How much will your budget allow? *

Is there anything else we should know about your dog's history or your current situation?

Dental Health Assistance Program

Dental Health Assistance Application

Contact Information

Greyhound’s Information

Medical Information

Financial Consideration

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