MEDICAL REVIEW

One of your clients applied to the Magic Bullet Fund for financial assistance for their dog's cancer treatment. Your client stated that he/she has granted permission for you to share information with the Magic Bullet Fund.

This form cannot be submitted by the dog's owner, it must be completed and submitted online by an employee of the clinic. It CANNOT BE FAXED, it must be filled in and submitted online.

The information you provide will be held confidential. We do not share the medical review or any clinic email addresses with clients. Magic Bullet Fund finances cancer treatment only. Not for treatment for other conditions, rescue protocols, palliative care, euthanasia or client's past due balance.

* IF this dog does not have a 50% chance of one-year survival with treatment, please close this form and send an explanation to the case manager - just reply to the email that the Case Manager sent you.

Questions: call 914-941-0159 or email the case manager.




Please type dog's first and last names.


Please type the name of the owner/s as it appears on the dog's account.












FORMAT: xxx-xxx-xxxx










If you know the clinic website, type it here:






We do not share clinic email addresses with clients. We do need a SECOND email address in addition to the billing address (next question).






This is a charity case! You would not be able to provide treatment for this dog without our assistance.Magic Bullet Fund is a non-profit and we request a discount.




Clinics can collect donations for the fund dog they have in treatment. The box will have this dog's photo on it.


We try to work with clinics that will work with us.
We can reduce the donations needed for a dog by purchasing chemo drugs (from a top distributor). We can pay for them from a Grant we received from Petco Foundation, not from the donations raised for the dog.

It is exactly the same as if you ordered the drugs, except we pay for them and have them delivered directly to the clinic. Drugs that a dog cannot use belong to the clinic.

*If you say yes, please fill in the form that will open after you submit this form.









Magic Bullet Fund can help with only ONE treatment modality. MBF no longer provides assistance for Radiation treatments.


Statistically or from anecdotal reports, from what you do know about the mass.


Statistically or from anecdotal reports, from what you do know about the mass.


Do you expect this dog will need additional cancer treatment (after surgery or chemo for which owner is applying for help)?
If Yes, explain.



Full cost only for the treatment that owner is applying for help with.
Standard fees - do not include any discounts.



What part of the treatment cost above has already been done?




Which drugs and on what schedule?




Also let us know (if this dog has lymphoma) if he has relapsed from a first remission.


Many clinics have in-house funding for clients who cannot afford treatment fees.


Yes/No
If yes, how much?
If no, why not?



Is there anything else we should know?


SURGERY - Upload standard estimate (without discount), for this dog's cancer surgery.

CHEMOTHERAPY -
Upload one estimate for each chemo drug in the protocol. I.e. for Madison Wisconsin, we need an estimate for 1 vincristine treatment, estimate for 1 cytoxan treatment and estimate for 1 adria treatment. Estimates should be standard fees, not reflecting discounts.

Or fax to 914-801-5856 instead. (Fax estimates only. The Medical Review has to be submitted online by clicking "submit" below).









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