This form is for individuals who need to replace their personal Healer’s Touch sculpture.

The cost is $65.

If your healthcare facility needs replacement sculptures, please contact your

DAISY Program Team for assistance.

Registration Information

Replacement sculptures can only be ordered for honorees who are registered with

The DAISY Foundation.

Search for the honoree in our directory:

https://www.daisyfoundation.org/daisy-award/honorees

Is the honoree registered with The DAISY Foundation?

YesNoNot Sure

Registered Honoree

Honoree's Full Name:

Enter the name of the honoree whose sculpture is being replaced

Organization where the Honoree received The DAISY Award:

Enter the honoree’s DAISY Spotlight page URL to continue to shipping and payment:

Copy and paste the link from the honoree’s DAISY Spotlight page.

Honoree Must Be Registered

The Honoree must be registered before a replacement sculpture can be ordered.

Please contact the DAISY Coordinator at the facility to have them submit the honoree's registration.

Not Sure if the Honoree Is Registered

You can search our Honoree directory to see if the Honoree has already

been registered.

If you cannot find the honoree, please contact your DAISY Coordinator at the

facility or reach out to us using our contact form.

Shipping and Billing Information

Please enter the address where the replacement sculpture should be shipped.
This address will also be used as the billing address for the credit card payment.

Shipping to Business or Residence?

First Name:

Last Name:

Recipient Full Name

Phone:

Email:

Street Address Line 1:

Apt/Unit:

City:

State:

Postal Code:

Payment Summary

Number of Replacement Healer's Touch Sculptures needed:

Replacement Healer's Touch Sculpture:

Total Charge $

Payment Information

Payments are processed securely through Stripe

Name on Card

Card Number

Code

Billing Email

Acknowledgment

By checking this box and submitting the online form, you agree to The DAISY Foundation collecting and storing your personal contact information. We may contact you if we have questions about your submission or to discuss next steps. To learn more, please read our Privacy Policy.

I Agree

Program ID

Funding Record Type

Contact Information