Request Assistance — Patients for Patients

Non-emergency Medical Travel Assistance Application

Complete the following form with the patient’s information. If selected for funding, documentation will be required to verify the patients qualifications. We may contact you for further information if the situation needs it. If you have any issues or questions, do not hesitate to email us at info@patientsforpatients.com

Primary Patient

First Name

Last Name

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Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

The patient has received a diagnosis from a medical professional

Yes

Travel plans and needs

Provide further details and needs for your trip such as location, mode of transportation, lodging or the patient needs a care giver to accompany them. DO NOT INCLUDE PERSONAL MEDICAL INFORMATION.