APPLICATION FOR SUPPORT
PATIENT INFORMATION
Patient Gender
*
Please Select
Male
Female
Non-Binary
Patient Name
*
First Name
Last Name
Patient Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient Date of Birlth
*
/
Month
/
Day
Year
Date
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CONTACT INFORMATION
MAIN CONTACT Name
*
First Name
Last Name
PRIMARY Phone Number
*
Please enter a valid phone number.
SECONDARY Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Main Contact Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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HOUSEHOLD INFORMATION
Annual Income
Occupation
Employer
Diagnosis
Date of Diagnosis
/
Month
/
Day
Year
Date
Do you have health insurance?
Yes
No
Do you have a prescription drug plan?
Yes
No
Do you have Medicare?
Yes
No
Do you have Medicaid (Title 19)?
Yes
No
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FINALIZE APPLICATION
What type of assistance are you interested in?
*
Please Select
Assistance with Medical Bills
A fun experience to help take mind off treatment
Participation in a charity event
OTHER
Please explain
Electronic Certification
*
I certify to the DezyStrong Foundation that I meet the eligibility requirements of the DezyStrong Foundation Relief Program, as described in this Application, and that all the information provide in or with this Application is true and correct.
Submit
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