The below application form is to be completed for any medical request that your hospital or health service centre requires assistance with. Your request will be reviewed by Humpty’s Medical Sub Committee and if approved will appear on Humpty’s Wish List in the hope a donor will come forward and donate.

Before you start the application process please note the following:

The application form should take less than 5mins to complete provided you have the following:

1. A current quote from the medical supplier
2. A jpeg image (pdfs are not accepted – the supplier will be able to assist you with this)
3. Text that describes the piece of equipment and what a difference it will make
4. You have downloaded and had signed the Department/Service Head Declaration Form

Requestors will need to complete the application form in full and submit as partically completed applications cannot be saved. Note applications are assessed by the Medical Sub Committee twice a year.

Requests for the first half of the year need to be submitted by 1 March or alternatively for the later half of the year 1 July.

Please don’t hesitate to contact us on 02 9439 0511 should you have any questions.