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Please email the following information |
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| YOUR INFORMATION: | ||
| • NAME • EMAIL ADDRESS • RELATIONSHIP TO THE SURVIVOR • DAYTIME PHONE NUMBER • EVENING PHONE NUMBER |
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| BURN SURVIVOR INFORMATION: | ||
| • NAME • AGE • BURN CENTER • PRIMARY OR TREATING PHYSICIAN • NATURE OF INJURIES • NATURE OF ACCIDENT • DATE OF ACCIDENT • ASSISTANCE DESIRED |
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| One of our counselors will contact you shortly. |
