Loved For Life
Services Request Form

Please fill out this form to request low-cost services at MHHS.

You need to fill this form out in one sitting. Please have images of your ID, proof of income, and/or public assistance forms ready.

An MHHS Representative will call you to collect payment and confirm an appointment after you have completed this form. Scheduling occurs Monday-Friday from 9am-5pm. We try to respond to requests within two business days.

If you have any questions, please reach out to 518.434.8128, ext. 218

Owner Information

First and Last Name
Current Address
Phone Number
Phone Number 2
Phone Number 3
Upload requirements
Would you like to add a secondary owner?
First and Last Name
Phone Number
Phone Number 2
Phone Number 3

Do You Qualify For This Program?

An MHHS staff member will need to review your documents to ensure that you income-qualify for services. Uploading documents does not automatically qualify you for services. 
Proof of Income can be either the two most recent pay statements or the most recent W-2s for all household wage earners. Proof of qualifying public assistance, such as SNAP, SSI/SSD, Medicaid, State Medical, Family, or Temporary Assistance, or Low Income Housing Assistance. 

An MHHS staff member will need to review your documents to ensure that you income-qualify for services. Uploading documents does not automatically qualify you for services. 
Upload requirements

Pre-Payment Alert

We will call you by phone to finalize booking of your appointment. In order to book an appointment from our low-cost services, we require pre-payment in full over the phone at time of scheduling. 

For a full list of services and pricing, please visit mohawkhumane.org/veterinary-services
How many pets would you like to schedule at this time?
Are you able to make prepayment in full?

Pet Information

Species
Sex

Services Request(s)

Services requested (please check all that apply):
Is your pet up-to-date on its Rabies Vaccination?
Upload requirements
Is your pet up-to-date on its Distemper Vaccination?
Upload requirements

Second Pet Information

Second Pet Species
Second Pet Sex

Second Pet Services Requested

Second Pet services requested (please check all that apply):
Is your second pet pet up-to-date on its Rabies Vaccination?
Upload requirements
Is your second pet up-to-date on its Distemper Vaccination?
Upload requirements