Toronto: (416) 837-0823 | Toll free: 1-800-599-8050
Beverly Hills (424) 335-0223 | Toll free: 1-844-548-6794

Donating Para-Medical Procedures to Accident and Cancer Survivors

Basma Hameed Clinic donates procedure to those who have gone through a tragic accident

Please fill out the form and tell us your story and why you need this!
* = required fields

First Name: *
Last Name: *
Date of Birth: *
(dd/mm/yyyy)
Address Line 1: *
Address Line 2:
City: *
Province: *
Country:
Postal Code: *
Phone Number: *
Email: *
Tell us your story: *
Word Verification: *