Burn Injury Medical Financial Aid Application
Personal Information
Full Name
Date of Birth
Gender
Female
Male
Other
Address
City
Phone Number
Email Address
Burn Injury Details
Date of Injury
Cause of Burn Injury
Location of Injury (Body Parts)
Severity of Burn
First Degree
Second Degree
Third Degree
Current Treatment Details
Financial & Medical Aid Information
Hospital Name
Doctor in Charge
Total Medical Expenses (So Far)
Amount Requested
Other Aid Received (if any)
Reason for Financial Support
Declaration
I hereby declare that the information provided above is true and correct to the best of my knowledge.