Blossom Bright Application

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Welcome to Blossom Bright for Lymphedema Sleeves, Bras, Wigs, and Toupees. At Blossoming Butterfly, we understand how challenging it can be to cope with hair loss or lymphedema. That's why we offer an assistance program to help individuals who are struggling to access the essential items they need to manage their condition. Our program covers the cost of lymphedema sleeves, bras, wigs, and toupees, and is available to eligible individuals who meet our criteria.

Blossoming Butterfly services Alachua, Duval, Marion and surrounding counties. Please complete this application and a member of the Blossoming Butterfly Team will contact you 48-72 hours after they are received.

****Any incomplete application will result in ineligibility for assistance. If you have any questions regarding the application or require additional assistance please call our office at (352) 214- 0155 or email info@blossomingbutterflyinc.com

Full Name *

Gender *

Are you of Hispanic, Latino, or of Spanish or ethnicity? *

Yes

Required

How would you describe yourself? *

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Required

Address *

Phone Number *

Referral Code

If you do not have a referral code please enter N/A

**Please be advised you will be required to submit provide proof of medical need, such as a doctor's note or prescription** Do you understand and agree?

Yes

Required

Please select all of the items you need? *Applicants can receive items on a one time basis*

Select all that apply

Wig

Toupee

Bra

Lymphedema Sleeve

Clear selection

Submit

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