OASIS MUSLIM CARE FOUNDATION (OMCF)(Formerly Oasis Muslim Care Fund)
12, Ilofa Road, GRA, Ilorin, Kwara State, Nigeria
www.oasismuslimcare.org, oasiscarefund@gmail.com+2348065655794, +2348020667393, +2348034189992, +2348035818938

Beneficiary Application Form (Patients)
Patient’s Personal Details
Name:
Gender:Date of birth:
Address:
Phone number:
Email:
Marital status:
Number of children:
Name and address of employer:
Next of Kin
Name of next of kin:
Relationship with next of kin:
Address:
Phone number:
Email:
Religious Affiliation
Religion:1Name of Imam/head of Islamic/religious body to which you belong:
Phone number of Imam/religious head:
Address of religious body:
Email (if available):
Medical Details (to be filled in conjunction with the doctor)
Hospital where patient is receiving treatment:
Patient’s hospital number:
Nature of ailment:
Duration of ailment:
Short description ofailment:............................................................................................................................................................
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Treatment plan:
On admission or outpatient:
Ward/ unit:
Duration on admission:(NB: please attach copies of relevant medical reports, tests, etc.)
Name of Doctor:
Doctor’s hospital and address:
Doctor’s details (address, phone number, email):Name, address, phone number and email of hospital for further treatment:
Financial Details
Estimated cost of treatment/amount required:2

Duration of treatment:
How much personal cash do you have:
How much cash have you raised from other sources:
Are you currently receiving assistance from any organisation? Yes/No
If yes, state details:

Doctor’s Attestation:
I hereby attest that the details provided by the patient above (medical and cost of treatment) are true and I
therefore recommend that he/she be assisted as required.

_________________________________________________
Doctor’s name and hospital (dept.)

Sign/Date(NB: if the patient is being managed by several doctors, any of the doctors may fill or attest the relevant
portions of the application.)
Involvement
What level of involvement do you request of OMCF?
Financial (state exact amount):
Other(s) (non-monetary):
Purpose of money required (drugs, medical tests, treatment charges, hospital bills, etc):
Consent
For verification and accountability purposes, we may need to put your personal details such as name, age,
medical history, digital picture, etc on our website and social media. Do you agree that we publicize suchinformation? Yes/No(NB: Your decision does not affect the success of this application in any way)3

Official (OMCF)
Application received on (date):
Application received by (name):
Date of meeting and deliberation on application:
Application approved? Yes/No
Why (if no):Communication of OMCF Board decision to applicant on (date)____________ by(means)___________________________.
Please fill this form and submit it to our office or scan and email to oasiscarefund@gmail.com.

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