Voucher Form | Malferd Lerner

Register For Your Voucher

Full Name

Phone

Gender

Male

Female

Home Address

Doctors Name

Who Recommened You?

Hospital

Friend

Other

Hospital Registration Card (This could be your appointment details; no medical details necessary)

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Please submit a current photo of yourself

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DISCLAIMER all services are carried out by professional beauticians and all products are safe to use according to the manufacturers guide such as nail varnishes, creams and oils. However, we cannot be held responsible for any allergic reactions that may occur due to your condition. But you can be assured that every effort will be made to keep you as safe. Please tick the box that you agree and have read this Disclaimer

WE HAVE TO VERIFY YOUR INFORMATION NOT TO BE INTRUSIVE BUT TO AVOID SCAMMERS SO OUR GIFTS WILL GO TO THE RIGHT PERSON.

YOUR INFORMATION WILL BE HELD IN THE STRICTEST CONFIDENCE AND WILL NOT BE PASSED ON TO ANY THIRD PARTY AND WILL BE USED SOLELY FOR THE PURPOSE OF VERIFICATION FOR YOUR FREE GIFTS AND FOR FURTHER GIFTS TO COME.

WE WILL DO ALL WE CAN TO HELP, SO THAT PEOPLE THAT ARE EFFECTED BY CANCER. GET THE SUPPORT THEY NEED.

Thank you, we will be in touch soon with more information on your voucher code. The Malferd Lerner Foundation