Fifty Shades of Pain, Inc Assistance Application
Thank-You for reaching out to us. Please complete the application below. We will follow-up within 2 days of the request being made.
Date
-
Month
-
Day
Year
Date
First and Last Name
*
Your Address
*
Cell Phone #
*
Your Email
example@example.com
Are You Currently Employed?
*
If so where?
Have You Been Diagnosed with Lupus?
*
Yes
No
Waiting on Diagnosis
Other
If so what type and when were you diagnosed?
Primary Physician Name
*
Primary Physician Address
*
Primary Physician Phone Number
*
Are You Seeing a Rheumatologist? If Yes, Complete Information Below.
*
Yes
No
Other
Rheumatologist Name
Rheumatologist Address
Rheumatologist Phone Number
What bills are you looking to get assistance with?
*
Briefly describe your need for this assistance (What is the Hardship? Loss of Income? Unexpected Bill? Hospitalization?)
*
Please upload Copy of Bill (#1)
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Choose a file
Cancel
of
Please upload Copy of Bill (#2)
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Choose a file
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of
If You do not have a copy of the Bill, please provide All information needed to pay. (Company Name, Name as listed on the bill, account number, address, phone, amount...Any information needed to make sure the bill is paid correctly)
Additional Comments
Signature
Submit
Should be Empty: