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Apply For Assistance

Application and Medical Eligibility Requirements.

Disclaimer: By completing this application, the applicant (or parent or legal guardian on behalf of a minor child applicant confirms the waiver and liability release has been received, reviewed, and signed. The applicant further acknowledges that, in order to participate in the Dysphagia Outreach Project, the applicant must reside in the United States or its designated territories and have had a medical appointment within the last three (3) months. Eligibility for assistance may be limited based on financial need generally determined using the recipient's home state Medicaid eligibility requirements.
Name, Relationship, Address, Email, and Phone #
Please include full name, business address, and phone #
Example: Stroke, Multiple Sclerosis, ALS, Down's Syndrome, Premature Birth, Failure to Thrive, etc....
Click or drag a file to this area to upload.
(Failure to include instrumental swallow evaluation [MBSS/FEES] may result in delayed application processing.)
(Proof of income is required.)
Click or drag files to this area to upload. You can upload up to 5 files.
(Failure to include proof of income may result in delayed application processing.)
Select all that you are requesting
(attaching treating doctors order/prescription, if available in next space)
Click or drag a file to this area to upload.
* I acknowledge that I understand how to contact The Dysphagia Outreach Project with questions, concerns, or to request more supplies.

Adult Travel Toothpaste

FREE

In stock

SKU: adult-travel-toothpaste Category: