APPLICATION FOR MEDICAL TRAVEL FUNDING

Please allow one week for our staff’s initial response to your application.
We are well aware that your needs are extremely time sensitive.

PATIENT















PERSON COMPLETING THE APPLICATION















REFERRING PHYSICIAN









HOW DID YOU FIND OUT ABOUT OUR ORGANIZATION?


BRIEF DESCRIPTION OF DISEASE


BRIEF DESCRIPTION OF DESIRED TREATMENT


DO YOU ANTICIPATE ADDITIONAL TRIPS?


IF SO, HOW MANY?



LOCATION OF FACILITY FOR CONSULATION AND/OR TREATMENT DESIRED
ALONG WITH CONTACT INFORMATION



HOW LONG IS YOUR ANTICIPATED STAY?


WHAT IS UNIQUE ABOUT THE CARE YOU WILL BE RECEIVING AT THE FACILITY
TO WHICH YOU DESIRE TO TRAVEL?


WHAT WAS YOUR CAREER/TYPE OF EMPLOYMENT BEFORE YOU WERE AFFLICTED
WITH YOUR DISEASE?


ANY ADDITIONAL COMMENTS YOU'D LIKE TO SHARE?



PATIENT'S EMPLOYER











SPOUSE'S EMPLOYER










By checking this box, I hereby authorize the Sarcoma-Oma Foundation to contact any employer referenced on this application to verify employment and stated income.

My signature below verifies that the information that I have provided is true and correct to the best of my knowledge and belief.