Application Form

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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?*
Consent for Use of Personal Information and Media*
- Yes
I hereby grant Sakinah Medical Outreach my consent to collect, use, store, and share my personal information, including my name, medical details, photographs, and video recordings, for the purpose of fundraising, public awareness, and donor communications for Sakinah Medical Outreach, both now and in the future. I understand that this consent applies to current and future campaigns and that Sakinah Medical Outreach will use these materials in a manner consistent with its mission and privacy standards.
Consent to Medical Communication*
- Yes
Authorize Sakinah Medical Outreach to contact my physician, hospital, or healthcare provider directly to verify and discuss my medical condition and treatment plan for the purpose of processing this application.
Declare Accuracy of Information*
- Yes
Certify that all information provided in this application is true, complete, and accurate to the best of my knowledge. I understand that any intentional omission or misrepresentation of material information will result in the immediate invalidation of my application and the withdrawal of any assistance granted.

Personal Details