MISCARRIAGE KIT / EARLY LOSS COMFORT PACKAGE REQUEST FORM
THESE KITS AND COMFORT PACKAGES ARE A DONATION (but are valued @ $25 each) MADE TO YOUR HOSPITAL ON BEHALF OF HALOS OF THE ST. CROIX VALLEY.

IF YOU HAVE ANY QUESTIONS, PLEASE  EMAIL: halos.helpproject@gmail.com
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NAME OF HOSPITAL OR CLINIC: *
FULL NAME OF PERSON COMPLETING THIS FORM:
YOUR EMAIL ADDRESS:
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PHONE NUMBER INCLUDING EXTENSION (IN CASE WE HAVE ANY QUESTIONS):
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