Please visit EB Info World 
To learn more about EB

EBAN Quality of Life Application

The EBAN Quality of Life Program is to help EB (Epidermolysis Bullosa) Patients that require specific and immediate help with either bandages or other products that enhance the life of an EB patient, such as medical procedures, wheelchair ramps, door handles, wheelchairs, special shoes and such. EBAN cannot accept applications that require assistance in paying things such as rent, mortgage, car payments and such.

The goal of the program is to help patients who would not receive medical treatment without EBAN's funds.

All fields must be completed for the application to be considered. All applications should be submitted with two quotes for the same service or products requested. Additionally all applications are subject to review before our board. The board will then vote on each case individually. Thank you for participating in our Quality of life program.

Please Note:  Unfortunately at this time, due to the nature of our organization, we are unable to help anyone outside of the United States. It's not that we don't want to, our status does not allow us to.
Our suggestion for families outside of the US is to contact someone at one of the Debra Organizations near you, such as Debra International or an EB group nearest you, possibly in your country/continent, all the ones we know of are listed here.

Patient's Full Name
Patient's age and form of EB
How was this type of EB determined and by who? Do you know what method of testing was used?
Patient's Mailing (Physical) Address
Patient's City, State, Zip
Patient's Phone Number
Patient's Alternate Phone Number
Email Address of Patient
	If you, the applicant, are not the patient, or if the patient is under 18 years of age, please provide the following information about the patient's caregiver:
Caregiver Full Name
Caregiver Email
Is the caregiver a parent/relative? Please explain the relationship
Caregiver Phone
Does the Caregiver live w/the patient?	Yes   No - If No, please fill out  your contact info below.
Caregiver Address
Caregiver City, State, Zip
Have you ever received help from EBAN before?	Yes   No
If yes, when? (Example: mm/dd/yyyy)
How did you hear about us?
	Tell us about the Patient's Needs
Describe what the emergency or needs of the patient's are that you need help from EBAN with.
Indicate the specific treatment or products needed, the urgency of them and any follow-up care required if any.
How can EBAN improve the Quality of Life of this patient? Please explain!
What is the estimated total cost of treatment or products needed?
How much are you able to personally contribute?
How much or what have you received from other donations?
If you have received donations from other sources, please list them here: Include the name of the contributing organization(s) and the amount or products they donated to the patient.
Describe your current financial situation. You may include how much you have spent thus far on items that are not covered or other relevant expenses effecting the need for EBAN's help
	Please tell us about the patient's Doctor. We may call to verify the diagnose.
Doctor's Group Contact Name
Doctor's Name
Doctor's Address
Doctor's City, State, Zip
Doctor's Phone
Doctor's FAX
If the person filling out this form is neither the patient nor the caregiver, please give us your name and phone number so we may contact you if we need to:	Contact Name: Contact Phone Number:
If you have anymore comments or questions, please fee free to let us know!

Please do not submit false or empty forms, THANK YOU! 

Copyright ? Epidermolysis Bullosa Action Network