Request for Parent Support
Cleft Friends a project of the Smile Foundation is a parent support group in South Africa. We understand what you are going through as our children were born with a cleft lip and/or palate too. Please complete this form so that we can contact you, if you wish. You are not alone.
Child's Name *
Your answer
Child's Surname *
Your answer
Child's date of birth *
MM
/
DD
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YYYY
Gender *
Where was the child born? *
Name of the hospital
Your answer
Diagnosis *
Is the child on a medical aid? *
Has the child had surgery? *
Child's ethnicity
Province *
City/Town *
Your answer
Suburb
Your answer
Parent/Guardian's Name *
Your answer
Parent/Guardian's Surname *
Your answer
Parent/Guardian's relationship to child *
Parent/Guardian's Contact Number *
Your answer
Parent/Guardian's Email Address *
Your answer
Prefered method of contact *
Parent/Guardian's Language *
How can Cleft Friends help you? *
Please contact me *
Where did you hear about Cleft Friends? *
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