Abundant Grace Grant Application
Name Of Patient
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
When is your thermogram booked for? If you have not booked it yet, then skip this question.
-
Month
-
Day
Year
Date
How many people are there in your household?
*
What is your annual household income?
*
Can you pay your provider at time of service?
*
Yes
No
If you receive the grant money, what kind of impact will this have for you?
*
What are you hoping to learn and gain from the Thermogram?
*
Can you make the required $5.00 Pay-It-Forward-Contribution online via Paypal?(You do not need to have a Paypal account) This contribution will assist others in need of Grant Money. This is required.
*
Yes
No
Would you like to become part of our Health Ministry under Abundant Grace Ministry? This will allow you to write off for tax purposes all services completed by the Thermography Center of Dallas. By marking YES, we will send you a form to fill out.
Yes
No
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Pay-It-Forward-Contribution
This contribution will assist others in need of Grant Money
$
5.00
Quantity
1
2
3
4
5
6
7
8
9
10
Payment Methods
Debit or Credit Card
Choose from one of the PayPal options to
make your payment.
Submit
Should be Empty: