Application Form
Our welfare grant is designed to provide support to as many people as possible. Please be aware that the grant amount has been revised to a maximum of
£100.00
as a one-off payment. If your patient is experiencing financial difficulties, they may find Macmillan's information and advice services on other grants and loans helpful:
Other grants and loans
.
This form must be completed by a member of your care team.
Healthcare Professional Contact Details
First Name
Last Name
Job Title
NHS Trust
Contact Telephone Number
Email
Please select here to state that you are a healthcare professional completing this form on behalf of a patient.
I confirm the above statement is true
Reason for Request
Patient Details
Patient Name
Patient Address
Patient's telephone number: We kindly request the patient's telephone number to facilitate a call for obtaining their bank details for payment.
Please state patient's email address, if known.
Date of Scan and/or Treatment(s)
Mode of Transport e.g. Plane, Train, Taxi
Distance to be Travelled
Anticipated Cost (Max £100.00 - one off payment)
Number of people travelling
Contact Information