Medical Eligibility Form - Zeus & PJ Charitable Foundation

FIRST CONSULTATION

Funding assistance related to the dog’s initial consultation at a specialist cancer centre

Select this option if you are a veterinary surgeon. This applies if the dog has been diagnosed with cancer and funding is needed for the initial consultation and necessary diagnostics at a specialist cancer centre.

CANCER TREATMENT

Funding assistance related to the dog’s cancer treatment at the specialist cancer centre

Choose this option if you are a specialist veterinary surgeon at the referral treatment centre. This applies if the dog has already been diagnosed with cancer and funding is needed for subsequent treatment plans.

Choose a Funding Option

What type of funding is being requested for the dog?(Required)

Funding assistance related to the dog’s initial consultation at a specialist cancer centre.

Funding assistance related to the dog’s cancer treatment at the specialist cancer centre.

You have selected funding assistance related to the dog’s initial consultation at a specialist cancer centre.

Please do not submit an application if the diagnosed cancer is on our list of cancer types not covered. In this case, please email [email protected] to let us know.

A separate application is required for funding to cover cancer treatment.

List of cancer types not covered

Dogs with the following cancers will automatically be declined funding due to poor prognosis (the listed cancer types typically have median survival times [MST] < 12 months with treatment).

– Gastric carcinoma
– Pancreatic carcinoma
– Prostatic carcinoma
– Stage IV oral melanoma

Certain forms of histiocytic sarcoma

– Haemophagocytic
– Disseminated

Certain forms of haemangiosarcoma

– Stage II-III splenic haemangiosarcoma
– Cardiac haemangiosarcoma
– Subcutaneous haemangiosarcoma

Certain forms of osteosarcoma

– Stage III appendicular osteosarcoma (e.g. distant metastasis at time of diagnosis)
– Extraskeletal osteosarcoma
– Vertebral osteosarcoma

Certain forms of lymphoma

– Mediastinal lymphoma
– High-grade/biologically aggressive cutaneous lymphoma
– Gastrointestinal lymphoma
– Large granular lymphocyte (LGL) lymphoma
– Any relapsed lymphoma

Note:

We will not fund treatment for mammary tumours if neutering at the time of treatment is advised by the responsible veterinary surgeon and this is not followed.

You have selected funding assistance related to the dog’s cancer treatment at the specialist cancer centre.

Please do not submit this application if the expected median survival time with the proposed treatment is less than 12 months, or if the diagnosed cancer is on our list of cancer types that are not covered. In either case, kindly email [email protected] to notify us.

We only fund cancer treatment, and do not fund rescue protocols, palliative care or euthanasia.

List of cancer types not covered

Dogs with the following cancers will automatically be declined funding due to poor prognosis (the listed cancer types typically have median survival times [MST] < 12 months with treatment).

– Gastric carcinoma
– Pancreatic carcinoma
– Prostatic carcinoma
– Stage IV oral melanoma

Certain forms of histiocytic sarcoma

– Haemophagocytic
– Disseminated

Certain forms of haemangiosarcoma

– Stage II-III splenic haemangiosarcoma
– Cardiac haemangiosarcoma
– Subcutaneous haemangiosarcoma

Certain forms of osteosarcoma

– Stage III appendicular osteosarcoma (e.g. distant metastasis at time of diagnosis)
– Extraskeletal osteosarcoma
– Vertebral osteosarcoma

Certain forms of lymphoma

– Mediastinal lymphoma
– High-grade/biologically aggressive cutaneous lymphoma
– Gastrointestinal lymphoma
– Large granular lymphocyte (LGL) lymphoma
– Any relapsed lymphoma

Note:

We will not fund treatment for mammary tumours if neutering at the time of treatment is advised by the responsible veterinary surgeon and this is not followed.

Section 1: Patient Information

1.1 – Dog's name:(Required)

1.2 – Owner's name:(Required)

1.3 – Signalment:

Age(Required)

Enter age (years/months)

Sex(Required)

ME

MN

FE

FN

Breed(Required)

Weight(Required)

Enter weight (kg)

1.4 – Is the dog in good condition?(Required)

Yes

No

Section 2: Primary Care Practice Information

2.1 – Veterinary practice:(Required)

2.2 – Contact detail:

Hospital/clinic Address(Required)

Street Address House number City Postcode Country

Telephone number(Required)

E-mail address(Required)

2.3 – Please name the referral hospital this case will be referred to, if funding is agreed.

Name of referral hospital (Write ‘UNKNOWN’ if not yet decided.)

Section 2: Treatment Centre Information

2.1 – Treatment centre:(Required)

Enter referral hospital/clinic name.

2.2 – Contact detail:

Treatment Centre Address(Required)

Street Address House number City Postcode Country

Telephone number(Required)

E-mail address(Required)

2.3 – Qualification:

Does the veterinary team managing this case include board-certified medical and/or radiation oncologists, surgeons, or internal medics?(Required)

Yes

No

Please provide details of relevant qualifications/experience of the veterinary surgeon(s) responsible for this case:(Required)

2.4 – Responsible veterinary surgeon:

If there will be one veterinary surgeon primarily managing this case, please identify here:(Required)

2.5 – Primary care practice:

Name of dog's primary care practice:

(If known)

Address of dog's primary care practice:

Street Address City ZIP / Postal Code Country

(If known)

Section 3: Clinical Information

3.1 – Cancer: (all sections MUST be completed)

Diagnosis(Required)

Enter the cancer type (E.G. Multicentric Lymphoma, Splenic Haemangiosarcoma…)

Diagnosis(Required)

Enter the cancer type, subtype, or immunophenotype.

Date of diagnosis(Required)

Clinical signs(Required)

Briefly summarise any clinical signs related to the tumour.

Tumor location(Required)

Please enter the tumor location.

Stage(Required)

Enter the stage (if not know please enter ‘unknown’).

Metastasis(Required)

Yes

No

If metastasis(Required)

Please describe the location and extent.

Grade(Required)

Please enter the tumor grade if applicable (if unknown, type ‘unknown’).

Confirm this is a first occurrence of this cancer (e.g. not recurrent or relapsed)(Required)

Yes

No

Prognostic factors

Please describe any relevant positive or negative prognostic factors for this specific tumour type.

3.2 – Other information: (all sections MUST be completed)

Prior and current treatment(Required)

Please briefly detail any cancer-specific or supportive treatment being given.

Ideal timeframe for referral(Required)

Please outline a timeframe within which referral is ideally required (Please note this is not within our control)

As far as you are aware, is this dog receiving funding for investigation/treatment costs from any other sources?(Required)

Yes

No

If Yes

Please outline.

3.2 – Treatment: (all sections MUST be completed)

Prior treatment(Required)

Please detail any cancer-specific treatment undertaken prior to this application.

Proposed treatment plan(Required)

Please summarise the specific treatment plan for this case, for which funding is being requested (e.g. forelimb amputation and adjuvant carboplatin chemotherapy for an appendicular osteosarcoma, or 19-week CHOP protocol for multicentric lymphoma).

Ideal timeframe for treatment(Required)

Please outline a timeframe within which treatment should ideally start.

Expected median survival time with proposed treatment(Required)

With proposed treatment | Please provide your best estimate of median survival time for this case with the treatment proposed.

Expected median survival time without any treatment(Required)

Without any treatment | Please provide your best estimate of median survival time for this case if no treatment were pursued.

Common complications associated with treatment(Required)

Please briefly outline any common possible complications/adverse effects related to the proposed treatment.

3.3 – Costs/estimate: (all sections MUST be completed)

Estimated cost of proposed treatment, as outlined in section 3.2(Required)

Please enter treatment estimate (in £).

Estimated total cost of managing potential complications, as outlined in section 3.2(Required)

Please enter treatment estimate for any common complications (in £).

As far as you are aware, is this dog receiving funding for treatment costs from any other sources?(Required)

Yes

No

If Yes(Required)

Please outline.

3.3 – Comorbidities:

3.4 – Comorbidities:

Does the dog have any significant comorbidities that are likely to have a poorer prognosis than the cancer?(Required)

Yes

No

If yes, please describe:

Please outline any significant comorbidities and treatment/associated prognosis.

3.4 – Other(Required)

Please provide any other relevant information / comments that would be useful for this application.

3.5 – Other(Required)

Please provide any other relevant information / comments that would be useful for this application.

One last step! Prove you’re a human—because only humans can help dogs fight cancer!

Medical Eligibility – Form

FIRST CONSULTATION

CANCER TREATMENT

Choose a Funding Option

You have selected funding assistance related to the dog’s initial consultation at a specialist cancer centre.

List of cancer types not covered

Certain forms of histiocytic sarcoma

Certain forms of haemangiosarcoma

Certain forms of osteosarcoma

Certain forms of lymphoma

Note:

You have selected funding assistance related to the dog’s cancer treatment at the specialist cancer centre.

List of cancer types not covered

Certain forms of histiocytic sarcoma

Certain forms of haemangiosarcoma

Certain forms of osteosarcoma

Certain forms of lymphoma

Note:

Section 1: Patient Information

Section 2: Primary Care Practice Information

Section 2: Treatment Centre Information

Section 3: Clinical Information

Section 4: Supporting documents