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Patient Information

* Required




Emergency Financial Assistance (EFA)     Financial Cancer Care (FCC) Program     Adult & Family Programs (AFP)





Yes No

Yes No

Yes No

Demographic Information

Your responses to the following questions enable Angel Foundation to better serve communities equitably. All responses are kept private and secured and will NOT be used for discriminatory purposes.




Yes No





Medical Information







Household Information


Yes No



Additional Information




Yes No

Yes (This is not required to receive assistance. If you choose yes, someone from Angel Foundation may contact you.)
No


Patient Release



I declare the information on this application is true and correct to the best of my knowledge. I understand that each application is reviewed on a case-by-case basis, and the final decision will be made by Angel Foundation.
I hereby give my verbal permission that this application and all information offered can be provided to Angel Foundation and discussed with my healthcare professional. I understand that all information reviewed is confidential.