Request Services

Part I - Patient Information
  1. (required)
  2. (required)
  3. (required)
  4. (required)
  5. (required)
  6. (required)
Part II - Person Submitting request
  1. (required)
  2. (valid email required)
Part III - Injury Information
  1. (required)
  2. (required)
Part IV - Funding Information
  1. Is hospital willing to accept payment at cost?
  2. Will physician donate their time?
Part V - Submit Photos & Medical Records
  1. Submit Photos via email to tsorkin@childburn.org
  2. Submit Medical Records via email to tsorkin@childburn.org
Part VI - Authorization
  1. 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.
  2. (required)
  3. 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.
  4. Captcha
 

cforms contact form by delicious:days

Bookmark and Share

Follow Us

Support

Support the Children's Burn Foundation when you shop at the following: