Emergency Medication Assistance Form

Epilepsy Reach is committed to standing by your side, and we understand that emergencies can arise unexpectedly, creating challenges in accessing vital medications. We are here to extend a helping hand through our Emergency Medication Fund.

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Physician Name & Contact Information *

Pharmacy Name, Address, & Phone Number *

Name of Medication & Dosage *

Name of Medication & Dosage

Do you currently have prescription drug coverage? *

Please include a copy of your prescription transcript from your pharmacy and a signed consent form for fasting processing *

Click or drag a file to this area to upload.

Additional Information

Program Consent Form

I agree to hold Epilepsy Reach Foundation exempt of all legal, financial, and any other liability that includes their employees, volunteers, personal representatives, affiliates, and any and all persons, firms or corporations liable or who might be claimed to be liable, whether or not herein named, none of whom admit any liability to the undersigned, but all expressly denying liability, from any and all claims, demands, damages, actions, causes of action or suits of any kind or nature whatsoever, which have or may hereafter have, arising out of or in any way relating to any and all injuries and damages of any and every kind, to both person and property, and also any and all injuries and damages that may develop in the future, as a result of or in any way relating to the Consenting Acts.

It is understood and agreed that this Agreement is made and received in full and complete settlement and satisfaction the causes of action, claims and demands mentioned herein; that this consent contains the entire agreement between the parties; and that the terms of this agreement are contractual and not merely a recital.

Furthermore, this consent shall be binding upon the undersigned, and his respective heirs, executors, administrators, personal representatives, successors and assigns.

Please note that this is only a 30-day supply. If further assistance is needed beyond 30 days, we can still help with the assistance of some of our partner programs!

This Consent has been read and fully understood by the undersigned and has been explained to me.

Type your full name below to acknowledge and confirm your consent. *

Date *

How did you hear about us? *

If you selected "referral" or "other," please specify.

Emergency Medication Assistance Form

Program Consent Form

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