Patient Assistance Application

The Save A Leg, Save A Life Foundation is committed to helping those in need with items such as diabetic shoes, dressing supplies, knee walkers, or other items used to help wound healing and prevent lower extremity amputation.

If you’d like to be considered for financial or device assistance, please fill out the application form below.

Alternatively, you may also download the form at the bottom of this page. After you have completed it, email it back to us for review: info@thesalsal.org or thesalsalorg@gmail.com. Thanks!

Patient Assistance Application
First Name
Last Name
Is applicant or parent(s) receiving any type of aid? (Check all that apply)