Request for assistance
Information about the child
CHILD'S NAME*
BIRTH DATE*
COUNTRY
CITY
DIAGNOSIS*
ADVERTISEMENT
Information about the child's treatment
NECESSARY TREATMENT*
CLINIC.
ACCOUNT AMOUNT*
USDEURRUB
Contact details
NAME OF THE APPLICANT*
PHONE*
EMAIL*
PHOTO OF A CHILD
RECENT MEDICAL DISCHARGE*
CLINIC BILL.
* by clicking on the button, you agree to the privacy policy
