Veterinary Clinic Voucher Remittance Form

One Health Organization > Veterinary Clinic Voucher Remittance Form

This form is to be filled out by an approved representative of a veterinary clinic that has chosen to accept vouchers for people to pay for veterinary services for their dogs and cats. Fill out one form per invoice.

Voucher Remittance Form

  • Accepted file types: pdf, doc, docx.
  • If you cannot upload the client invoice, send it by FAX to 216.455.0980 and call the first time you try to assure delivery. Our office can only accept a FAX from a 'modern' FAX machine.

    If you cannot upload the client invoice OR send a FAX, please mail the invoice to: One Health Organization, ATTN: Voucher Program, 27600 Chagrin Blvd, Ste 400, Cleveland, OH 44122

  • You can upload a photo taken of the pet. Any photos will be used by One Health Organization to promote the program to donors and others, and will be considered the property of One Health Organization. Photo credit will be given, if desired.

  • Accepted file types: jpg, gif, png.
  • By submitting this electronic form, I assert that I/my company: 1) provided the service(s) described on the invoice, 2) provided the service(s) in accordance with the voucher guidelines, 3) understand that falsifying any information in association with this voucher will lead to legal action against me/my company by One Health Organization to the full extent of the law, and 4) that a W-9 form must be on file at One Health Organization before any funds can be sent to the Veterinary Clinic for these vouchers.

  • This field is for validation purposes and should be left unchanged.