Funding Assistance Please complete the attached form and we will revert back to you as soon as the form is reviewed. Your Name (required) Date of Birth (required) Address (required) Your Email (required) Your Phone Your Mobile Do you have a medical card ? ---YesNo Do you have medical insurance (e.g. VHI)? ---YesNo Is the treatment available in the public health system? ---YesNoDon't Know Can you afford the proposed treatment? ---YesNo Your Message It's only fair to share...000
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