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Patient Assistance Application

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    Patient Information
    Full name of child/patient*
    Date of birth*
    Gender*
    Primary diagnosis / special needs*
    Medical provider or clinic name*
    Provider phone number*
    Parent / Guardian Information
    Full name of parent/guardian*
    Relationship to child*
    Address*
    City/Province*
    Phone number*
    Email address*
    Household Information
    Number of adults in household*
    Number of children in household*
    Estimated total monthly household income (before taxes)*
    Services Requested

    Please check all that apply and list sizes and details where needed:

    Child's Weight (kg)*
    Changes per day

    [View diaper size chart]

    Shakes per day
    Current Food Intake:
    Dairy Allergy? YesNo
    Gluten Allergy? YesNo
    Other essential supplies needed:(Items not guaranteed mainly for survey purpose for future)
    Medical / Laboratory Information

    A letter from a physician or therapist on official letterhead is required.

    Last blood work date (CBC, Vit D, B12):

    Were the following labs included?

    CBC: YesNoUnsure
    Vitamin D: YesNoUnsure
    Vitamin B12: YesNoUnsure
    Shipping
    Required Documents (Uploads)

    Please attach clear copies of the following:

    Child's Photo:
    Proof of Identity (Birth Certificate):
    Proof of Address:
    Physician Letter (Official Letterhead):
    Labs (if any):
    Consent, Authorization, and Acknowledgment
    Signature of parent/guardian (Type Name)*
    Date*
    Download the Form