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1114 North Court St.
Box 122
Medina, Ohio 44256




Financial Assistance Application


Your Name:               ____________________________

Address:                   ____________________________

Date of Application:   ____________________________
Referral Source:         ____________________________
Phone Number:          ____________________________
Age:                            _______


Situation: (Describe current medical crisis)

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Name and Address of company providing service or equipment :

___________________________________________________________________________________________________


___________________________________________________________________________________________________



Phone Number and Contact information for check:

___________________________________________________________________________________________________


Amount of Request:  $______________