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Patient Name *

First Name

Last Name

Applicant Name

(if different from patient)

First Name

Last Name

Patient Birthdate *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

What treatment program are you a participant in? *

Check all that apply

Tolerance Induction Program (TIP)

Oral Immunotherapy

Sublingual Immunotherapy (SLIT)

Other

Length of total treatment plan: *

0-6 months

6-24 months

2-4 years

4+ years

Do you travel more than 50 miles for medical treatment? *

Yes

No

What immediate financial assistance are you seeking? *

(Check all that apply and specify estimated costs where possible.)

Quarterly payment to TIP

Sublingual Immunotherapy (SLIT) payment assistance

Airline ticket assistance

Hotel/lodging assistance

Car rental/transportation assistance

Specialty food costs related to treatment

Other medical-related expenses

What other funding sources have you pursued? *

(Check all that apply and provide details where applicable.)

Insurance reimbursement attempts

Employer HSA/FSA funds used

Other nonprofit or medical assistance grants applied for

Crowdfunding (GoFundMe, etc.)

Family/friends assisting with costs

How urgent is your financial need? *

(This helps us prioritize families in critical situations.)

Immediate (treatment is at risk without assistance this month)

High (we are struggling to cover upcoming payments within 1-3 months)

Moderate (we can manage for now but will need support soon)

Ongoing financial hardship (treatment costs are a long-term burden)