Abundant Grace Grant Application
Name Of Patient
Please enter a valid phone number.
When is your thermogram booked for? If you have not booked it yet, then skip this question.
How many people are there in your household?
What is your annual household income?
Can you pay your provider at time of service?
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.
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.
( X )
This contribution will assist others in need of Grant Money
Debit or Credit Card
Credit Card Number
Please click one of the PayPal options to complete payment and
Should be Empty: