Nonmedical Requests | Children’s Burn Foundation

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Nonmedical Requests

Non-Medical Funding Application

Please provide us the following information using our secure on-line form. All information is confidential, and will be used solely for the purpose of evaluating your request for funding.

Items with an ‘*’ are required.

Section A: PATIENT INFORMATION

Name of Patient*

Address*

City*

State

Zip/Postal Code

Country*

Parent or Guardian*

Telephone*

Patient Date of Birth

Section B: PERSON SUBMITTING REQUEST

Your Name*

Title

Organization

Telephone*

Email*

Section C: FUNDING INFORMATION

Describe Services Needed*

Approximate Cost*

Please allow 48 hours for a reply.

RECOVERY SERVICES

800.949.8898