Application Form

25%

Medical Details:
Nature of ailment*
Duration of ailment*
Short Description of the ailment*
Attach Supporting Document*
Drop files here or
You can attach more than one file
Name of Hospital/Doctor*
Address of Hospital/Doctor*
Street Address State / Province / Region
Doctor's Phone Number*

Financial Details:
Estimated cost of the treatment*
How much of the cost do you personally have towards the treatment*
How much money have you raised from other sources*
Are you currently in receipt of any financial assistance from any organization (or engaged in discussion for such assistance)*
- Yes
- No
State Details*

Sakinah Involvement
What level of involvement do you require from SAKINAH?*
Terms and Condition*
- Yes
By signing this form, you declare: Your consent for Sakinah Medical Outreach to; Use your details, including your picture, for the purpose of its normal crowdfunding campaigs and fundraising in the event that your application is successful; Communicate directly with your doctor/hospital in respect to your medical condition; That all information furnished to Sakinah Medical Outreach for the purpose of assessing your application is genuine and accurate to the best of your knowledge. Any willful omission of vital information will irrevocably invalidate the application and assistance approved.
Consent Terms and Condition*
- Yes
I hereby give voluntary consent on behalf of my (self, son, daughter or person for whom I have a legal responsibility) to receive medical treatment sponsorship under the rules of Sakinah Medical Outreach. I understand that such medical treatment may include surgery, medications, risks, and discomforts, and will be performed by duly licensed practitioners. I hereby accept full liability incurred through such medical treatments. I agree that no liability in respect of injury, loss or damage whatsoever shall attach to the Sakinah Medical Outreach, its subsidiaries, affiliates, employees, volunteers or agents. Also, Sakinah Medical Outreach may terminate this Agreement or discontinue the services rendered through it at any time in its sole discretion.

Personal Details