DAST International is a nonprofit organization helping deserving candidates receive hip resurfacing surgery for free or at a reduced cost DAST International is a nonprofit organization helping deserving candidates receive hip resurfacing surgery for free or at a reduced cost. All donations help candidates receive surgery. The Board of Directors volunteer their time to DAST International. DAST International is a nonprofit organization. Doing a service to help others one hip at a time.

Home Candidates Application Form Participating Surgeons Candidates Hip Stories Helpful Websites Contact

Candidates Form

Name
Email Address
Male or Female
Date of Birth
Do You Own or Rent Your Home?
Phone Number Including Area Code
Employer Name

Employer Address

Employer Phone Number

What Type of Work Do You Do?

Current Income Per Year

Source of Income - employment, welfare, retirement, SS

Name of Primary Care Physician:

Name of Orthopedic Surgeon who diagnosed your hip problem:

What is the date of your last hip x-ray?

Have you had a recent bone density scan?

What other (if any) health conditions or major surgeries have you had?

Include Doctor Information - report  and diagnosis

Explain your need for hip resurfacing briefly, including symptoms, pain, problems and need for financial help.

What activities or sports are or have you been active in?
 

Insurance Information - if none, why?

Your Digital Signature allowing us to do a credit check.

Date
   Form Mail by FormToEmail.com

After you are told that you are a Hip Resurfacing candidate by a participating doctor

 and are informed that you are a DAST Candidate, we will require the following information:

 2 years tax returns
Social Security Number
Drivers License Number
Signed HIPAA form
 

 

Board of Directors

 Founder of DAST:  Vicky Marlow

HR Surgery with Dr. Bose 12/01/05

Carisa Sherwood
Alan Ray Hip Resurfacing with Dr. De Smet 2004
Patricia Dukes

HR Surgery with Dr. Gross 6/19/06

 Alan Ray

HR Surgery with Dr. De Smet 12/15/04
Desmond Tuck - Consultant to DAST

HR Surgery with Mr. Treacy 2001

 Patricia Walter - Webmaster

HR Surgery with Dr. De Smet 3 15/06
Copyright 2007 DAST International a Non-profit Organization

View My Stats