Care Package Request Form

People at risk for limb loss are an overlooked population. Treatment and recovery can be life-changing, frightening, and traumatic physically, emotionally, and financially. The LPF Limb-Risk Care Package Program makes a difference for people during treatmentwho are experiencing extended periods of bed rest during their recovery. To help them know they are not alone, we provide a care package of basic comfort items along with a beautiful handmade quilt.

To receive a care package, please complete the form below. To qualify, the patient must be in active treatment for limb-threatening issues* pertaining to the treatment of tumor, trauma or infection and reside in the Rocky Mountain Region (AZ, CO, ID, KS, MT, NE, NM, UT, WY).

*limb-threatening issues relating to serious risk of losing an arm or a leg not due to diabetes.

Your Contact Information

LPF Limb-Risk Care Package Program

Name

First Last

Phone

Recipient Contact Information

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Age

My/Their condition was caused by:(Required)

Tumor

Trauma

Infection

Facility Name

Treating Physician(Required)

Gift Message