Veterinarian Partner Form

Diesel Memorial Fund

Our nonprofit honors the legacy of Diesel, who overcame ten years of medical issues and trauma. Kaajal Tiwary, the founder and president of Diesel’s FootPrint, understands the challenges and emotional toll of securing the funds and support needed to manage serious – acute, or chronic medical conditions. We continue his legacy with a mission to help others.

Through Diesel’s Fund, we provide financial support to low-income families who cannot afford costly medical care. Our application process ensures donations help pets in need and go directly to the veterinary hospital.

"*" indicates required fields

Pet Guardian's Name*

Pet's Name*

Name of Veterinary Specialty Clinic*

Treating Veterinarian Specialists Name*

Treatment Plan and Prognosis

Detailed Treatment Estimate*

Max. file size: 300 MB.

Miscellaneous Support Document #1

Max. file size: 300 MB.

Miscellaneous Support Document #2

Max. file size: 300 MB.

Has a deposit or payment been made for the recommended care?

To the best of your knowledge, is the owner applying for assistance from another organization?

If YES, which one?*

Primary Veterinary Clinic and Veterinarian's Name*

Veterinary Signature*

Please type in treating veterinarian's name