APPLICATION FOR ASSISTANCE

Please complete this online application or contact Linda Gilson, Wilson Clinic,212 Carlanna, Suite 100, 225-4104.
Name
Street address
Mailing address
City
State
Zip code
Home Phone
Fax
E-mail
Diagnosis
Physician
Assistance Requested:	Financial Assistance for medical treatment or travel Please describe what is needed - medication, specialized treatments, travel, lodging, etc. We are only able to reimburse for documented expenses and will need receipts for our records. (Note: If travel assistance is requested, please state whether this treatment is available locally and, if so, your reason for leaving.) Financial Assistance for screening exams Please state what type of screening exam is required.