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Patient Request for Assistance

Please fill out the form below to let us know how we can help you.  Certain types of assistance may be limited to individuals whose household income is at 250% of the Federal Poverty Level or below.  Do I qualify?  Click here to view the Federal Poverty Level Page.

Please note that assistance with Transportation and Childcare are only available based on funding. 

Lymphedema garments are available based on in-stock inventory.  We are unable to provide additional orders or custom garments at this time.

How Can We Help? - 2015

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