Request Form
Our mission is to help those who have difficulty in accessing healthcare in fighting with chronic pains that are impacting their working, education and livings. This program is to offer FREE PainKARE device to senior, woman and low income, and to inspire them for a better life.

How it works:
Complete this form with a US continental address, and support documents
Send form and documents to for a qualification review.
An email will be followed to qualified applicant with instructions to proceed.
The device delivery is on monthly basis contingent on the fund raised in the month.

Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms