"No act of kindness, no matter how small,
is ever wasted."
Aesop (620 BC - 560 BC)
THE IMPORTANCE OF LITTLE THINGS
"QUICK CHECK PROGRAM" EXPLAINED
"QUICK CHECK PROGRAM" APPLICATION FORM
CONTACT US !!!
Our "Quick Check Program" Application
fill out before submitting.)
Organization's Phone Number
Requestor's Relationship to Patient
Patient's Primary Diagnosis
Patient's Present Prognosis
Describe Item or Service to be Purchased
Reason For Purchase
Anticipated Cost (If possible, please attach photo of or link to item or service)
Please certify to the following by check-marking each statement:
a. The above-stated information is true and accurate.
b. The above-designated patient is currently receiving care from your organization.
c. Said patient and patient's family lack the funds to acquire the requested item or service.
d. The above-referenced organization for which you work DOES NOT have funds available with which to purchase the requested item or service.
e. The requested money, if granted, will be promptly used for the stated purpose herein.
f. Said item or service will be immediately purchased with TILT's funds and timely delivered to said patient.
Requestor's Signature (type)
Date of Request
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