Request Reimbursement

We at HonorBridge take pride in our work and would like your feedback to help us improve our process and to address any concerns in a timely manner. Please complete the quick survey below which will provide valuable feedback for us and allow you to submit for reimbursement.

Tissue # or Donor Name(Required)

Date of Donation(Required)

Month

Day

Year

Funeral Home Name(Required)

Address

Street Address City State ZIP Code

Did the Funeral Home receive a call from HonorBridge during the donation process?(Required)

Yes

Unsure

Were all family requests for viewing/service times met?(Required)

Yes

Were there signs of excessive leaking from the recovery site or incisions?(Required)

Yes

If so, where?

Was the donor embalmed?(Required)

Yes

Additional Comments

Name of embalmer(Required)

Did you utilize the material in the Funeral Home Packet?(Required)

Yes

If so, what?

Are you aware that there are print materials/promotional items that HonorBridge can provide to you in assisting donor families? If you would like them, please list them below.

Name of person completing this form(Required)

Phone(Required)

Email(Required)

Date of service(Required)

Month

Day

Year

Select reimbursement amount (for embalmed donors only)(Required)

Skin - $200

Bone - $250

Reimbursement is for bone OR skin. Options cannot be combined for a larger reimbursement.