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FUNDING

Applying
for Help

You can make an application for funding by completing the form below.

Name

Email Adress

Address

Date of birth

Please summarise the treatment you have received so far:

What additional treatment or equipment has been suggested for you at what cost?

Why do you need financial assistance? Do you meet any of these criteria?

Universal Credit – (Inc. Job seekers allowance

income support & incapacity benefit)

Pension credit

Disability Living allowance (DLA)

Personal Independence payment (PIP)

Any patient who meets the eligibility criteria for the Help with Health Costs Scheme

You will be required to provide evidence of the above.

I can confirm that the above details are correct and understand that I will be required to produce evidence to support my claim.

I confirm the above

Thanks for submitting!

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100%

of our donations
will go towards supporting
those who need us

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