Light A Candle Application

Initial Request Form

*All request forms valid for 6 months from date of initial request or completion of active treatment*

Section 1: Patient Information

Patient Name(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Patient Birthday

Is the patient 18 years or older?

Yes

Patient Guardian Name(Required)

Phone(Required)

Email(Required)

Good time to contact

Day

Evening

Weekend

Gender(Required)

Male

Female

Prefer not to answer

Self-Designated

Self-Designated Gender:

Patient Diagnosis(Required)

Date of Diagnosis(Required)

Stage of Cancer(Required)

Is patient undergoing active treatment?(Required)

Yes

Please check services requested:

Gas Card

Grocery Assistance

Other

Please provide description of other service(s) needed:

Initial request (other than physician/certified representative) made by:(Required)

Section 2: Certified Representative Information

A certified representative is a doctor, nurse, case manager, or social worker.

Physician Name:(Required)

Physician Telephone:(Required)

Representative Name:

Title:

Representative's Hospital or Clinic Name:

Telephone:

Country Phone Number

Fax

Country Phone Number

Applications are only accepted through a certified representative. A certified representative is defined as a patient's doctor, nurse, case manager, or social worker. All sections of this form must be truthfully completed. Any false, incomplete or misleading information will result in an automatic denial. Consideration shall be determined based on all factors as noted in this application and in accordance with the Light A Candle Program policy.

Signature

As the initial requestor, please have patient sign request to give his or her consent to provide information as required for application:

Patient Signature. Use your pointing device or finger.(Required)

Typed Patient Signature(Required)

By typing your signature here, you are electronically signing and attesting to the truth and accuracy of your answers.

Initial Request Form

Section 1: Patient Information

Section 2: Certified Representative Information

Signature