We care about the needs of our community! 

Bialy's Wellness Foundation is tackling an exciting project that includes surveying pet owners/caretakers of pets with mobility impairments. This survey will provide us with information necessary to create and implement programs furthering our mission and serving you better.

Please complete the form below if you would like to partake in the survey.
The more data we have the more we can help! 

**Note: Your PERSONAL information will not be shared with anyone else.**

Contact (Part 1/6)
Name *
Mailing Address
Mailing Address
May Bialy's Wellness Foundation contact you regarding your pet or caregiving experience? *
Pet's Information (Part 2/6)
Pet's date of birth? *
Pet's date of birth?
Best guess/approximate if unknown.
Pet's gender? *
Was your pet spayed/neutered? *
Did your pet have insurance? *
Is your pet still living? *
Diagnosis (Part 3/6)
Your pet's suspected or confirmed diagnosis: *
I took my pet to consult with the following specialist(s): *
Please select all that apply.
What diagnostics were performed? *
Please select all that apply.
Was surgery an option? *
Was your pet fecal or urinary incontinent? *
Mobility (Part 4/6)
How would you describe your pet's mobility at the start of diagnosis or when you first started caring for your pet (i.e. if the pet was a foster)? *
Please select all that apply.
How did your pet's mobility change? *
Did your pet utilize any of the following assistive devices or supplies? *
Please select all that apply.
Pain and Care (Part 5/6)
Did your pet experience any of the following? *
Please select all that apply.
How often did your pet experience pain or discomfort? *
Perspective and Resources (Part 6/6)
I have felt weighed down, worried, anxious, or nervous by my pet's health concerns. *
I have struggled financially because of my pet. *
I felt comfortable leaving my pet: *
Please select all that apply.
When caring for my pet I wish I had access to: *
Please select all that apply.
Please include any challenges, memorable moments, quality of life concerns, physical limitations, or stories.