Request Services

Part I - Patient Information

Patient Full Name(required)
Street Address(required)
City(required)
State (required)
Zip Code(required)
Country(required)

Part II - Person Submitting request

Your Full Name
Title
Organization
Street Address
City
State
Zip Code
Country
Telephone(required)
Email(valid email required)
Relationship To Patient

Part III - Injury Information

Hospital for Treatment
Original Date of Injury
Original Date Unknown?
Severity of Injury(required)
Cause of Injury(required)

Part IV - Funding Information

Describe Services or Funding Needed by CBF* Approximate Amount Requested, if known Other Funding Sources Available
Is hospital willing to accept payment at cost?
Yes No Unsure
Will physician donate their time?
Yes No Unsure

Part V - Submit Photos & Medical Records

Submit Photos via email to tsorkin@childburn.org
Submit Medical Records via email to tsorkin@childburn.org

Part VI - Authorization

By entering my electronic signature below, I verify that I am authorized to share photos and medical records of this child with the Children’s Burn Foundation, and I authorize the Children’s Burn Foundation to share the submitted photos and records with medical experts for the sole purpose of ascertaining possible treatment for the child, and for no other purpose without further permission.
Type Your Full Name (e-signature)(required)
We will contact you as soon as a decision has been reached, or if we require more information. Please allow 48 hours for a reply.
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Children’s Burn Foundation
5000 Van Nuys Boulevard, Suite 450
Sherman Oaks, CA 91403
800-949-8898 /

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