Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name of Submitting Medical Professional *Only employees of Urology of Virginia may submit this application on behalf of patients.Name of Patient *FirstLastDOBPhysician NameDiagnosisSpecific Assistance RequestedUtility BillTransportationNutritional SupportMedical EquipmentHardshipOtherSURF offers this assistance to patients of Urology of Virginia to support NON-MEDICAL needs only. It is a one-time gift.AUTHORIZATION TO SUBMIT ON PATIENT'S BEHALF *By Checking this box, you confirm that the patient authorizes the submitting medical professional to submit the application on their behalf.Statement from Submitting Medical ProfessionalPlease explain the request for funding.Confirim the following Mini-grant criteria: *Patient is a legal resident of the U.S.Patient has insurance or Medicaid (not self pay)Patient's account is not presently in collectionsPatient's balance at Urology of Virginia is between $501 and $1,000**There may be other resources available through the "financial hardship" program at Urology of VirginiaSubmit