Medical Aid Application

Treatment, medication, surgery or mobility aids.

Applicant Details

Full name (in English) *National Identity Card (NIC) number *Contact number 1 *Contact number 2 Address (in English) *Grama Niladhari Division Divisional Secretariat Division District *Monthly family income (LKR)

Medical Details

Patient's name *Patient's age Medical condition / diagnosis Type of aid needed *Hospital / clinic Estimated cost (LKR) Describe the medical need *

Required Documents

Please attach the following where possible. Anything you cannot attach now, our team will collect or request during verification.

National Identity Card (NIC) copy *Medical report / diagnosis Cost estimate (if available) Other supporting documents

Each file max 8 MB · PDF, JPG or PNG.

I confirm that the information provided in this application is true and accurate to the best of my knowledge, and I understand that any false information may invalidate my application.