Claim Form

Hero's Name (required)

Ned's Wish Registration Number (required)

Your name (required)

Telephone Number (required)

Email Address (required)

Reason for Treatment (required)
IllnessInjury

Hospital / Vet Clinic name (required)

Treating veterinarian

Have you filed a claim for this illness/injury with us previously (required)
YesNo

If yes, what date?

Have you paid the prescriptions/Vet bill in full? (required)
YesNo

If yes, how much have you paid?

Please attach receipt

Do you have Pet insurance? (required)
YesNo

If yes, provider name

Is the dog fully retired or working in another capacity? (required)
RetiredWorking

If working please describe:

Submission of this claim form authorizes all veterinarians that your pet has received treatment from to provide us with a copy of your pet’s medical records and confirms all information provided is true and accurate to the best of your knowledge and belief.

Submit this completed claim form and veterinary/ prescription receipt/invoices the Submit button to Neds Wish.

In order to avoid delays, all claims submitted must include a fully completed claim form and accompanying itemized receipt/invoice(s) with all treatment descriptions and charge amounts clearly visible.

Any Person who knowingly presents a false or fraudulent claim for the payment is guilty of a crime and may be subject to fines and confinement in prison.

I agree to the above terms and certify that the information provided is correct to the best of my knowledge