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Provider Pledge Form for Donated Services
The Foundation for Airway Health is asking practitioners to support airway health through pledging a personal commitment to provide one (or more) free service(s).
Please note that this is NOT a donation to FAH and there is no tax benefit implied.
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Email
*
Your email
Please enter your name
*
Your answer
What is the name of your practice or institution?
*
Your answer
Location of services donated (city, state, province, country as applicable):
*
Your answer
What type of treatment do you plan to pledge for discounted or waived fees?
*
Dental/Orthodontic
Medical
Physical & Rehabilitative Therapy
Sleep & Sleep Therapy
Breathing & Breathing Therapy
Myofunctional Therapy
Wellness & Complementary/ Holistic Medicine
Other:
What providers within your practice or institution have committed to pledge these services?
*
Your answer
Please provide details and an approximate value of the services pledged, as per your practice or institution's cost scale.
*
Your answer
A copy of your responses will be emailed to the address you provided.
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