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Veterinary Expense

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					   DO NOT FAX – Faxed invoices will not be accepted except from Canada (Canadians may fax to (415) 499-4035)


                                                                      Name:
                                 Veterinary Expense
                                 Reimbursement Request Form           Address:
                                                                      City/State/Zip:
                                 Mail Request to:
                                 Guide Dogs for the Blind             Dog Name and Tattoo:
                                 Attn: Accounting Dept.
                                 P O Box 151200                       Current Status:
                                 San Rafael, CA 94915-1200            Date of Birth:
                                                                      Accounting Code:           (for accounting use only)




Name of Clinic/Person to be Paid:                             Treatment Date:                      Invoice #:

Name:                                                             Total Charges:                    $
Address:                                                          Less Discount/Donation:           $
City:                   State:                 Zip:               Total Reimbursement Request:      $

Phone:                                                            Donation Made By:
E-mail:                                                           Approval #:


Mail this completed reimbursement form with a detailed invoice/receipt to the above address.

Reimbursement requests must be submitted to GDB within 90 days of the date on the invoice/
receipt. Due to administrative constraints GDB will not consider requests for reimbursement on
receipts older than 90 days. Our veterinary reimbursement program runs on a fiscal year from July 1
to June 30.

GDB restricts procedures and products we will reimburse for. Please review the Veterinary
Financial Assistance policy (viewable online at www.guidedogs.com/vet) prior to submitting your
request.


Questions? Call (800) 295-4050 and ask for extension 4117
   For questions about payment status or submitting an invoice, press 1
   For questions about treatment authorization or veterinary care decisions, press 2


Thank you for providing quality care to our dogs! Donating services assists us in fulfilling our
mission. As a non-profit organization, Guide Dogs for the Blind relies upon generous donations from
many individuals and organizations. We greatly appreciate any discounted veterinary services.


Diagnoses:      Please provide diagnosis related to this visit.        Location:                                  Right:     Left:
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