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Patient Application Form

Patient Application


Download the form, fill it out completely and email it to:


or mail to:

  • Setting Them Free
  • 601 S. Windsor
  • Mesa, AZ 85204

Your application will be reviewed and you will be contacted within 2 days by a representative of Setting Them Free.

After acceptance, we will need:

  1. A quality digital photo of the upper body and other photos you may want to include in your fundraising site.
  2. Your medical story and why you have a financial need. This will be posted on your fundraising site also. Don’t worry, we will help you edit your story,  if requested.

Thank you,

Margaret Manning

President of Setting Them Free