If you know any low-income individual or family, that receives Public Assistance, Medi-cal, and/or in is need on our dressing service, please let us know by returning the form below. Let us know the circumstances for requesting a referral (unemployed, under-employed, new to the area, homeless, family emergency, etc.): 

Name *
Name
Phone *
Phone
Translator Needed
Phone
Phone

Upon receipt of this form, the Bloom Program Director will contact the individual(s) to determine eligibility and schedule an dressing appointment.  If you have any questions, please contact Bloom Program Director at (415) 717-5115.  Thank you.  

The information contained in this document is strictly confidential and is intended for the addressee only. The unauthorized use, disclosure, copying, alteration or distribution of this document is strictly prohibited and maybe unlawful.