Roche Transplantation | Community Support | The Bear Hugs Program

Bear Hugs Program Request Form

Please print this page, complete the information, and fax it to 1-800-895-3868.

Type of transplant:

Date:

Transplant coordinator name:

Institution:

Address:

City:

State:

Zip:

Phone #:

Institution's E-mail address:

Transplant
Coordinator Signature:

Date:

I hereby verify that this request form is for a Bear Hugs Program™ Kit, a complimentary
program offer sponsored by Roche Laboratories Inc. I understand that the components
of the Bear Hugs Program™ are for the benefit of transplant patients and will be
provided at no cost to me or the institution I work for.