ALS Association Wisconsin Chapter: Fighting on Every Front to Improve Living with ALS

Please make a gift and support
The ALS Association and those
fighting this disease.

Patient Registration

1. Personal Contact information

Name:
Address:
Address 2:
City/Town:
State:
ZIP/Postal Code:
Country:
Email Address:
Phone Number:

2. I am a:

Person with ALS

Spouse

Family Member

Friend

Health Care Professional

Interested Party

3. What is your date of birth?

4. Gender

Male

Female

5. What is your marital status?

Married

Single

Divorced

Widowed

6. If married, what is your spouse's full name?

7. What is the name and phone for your emergency contact?

8. Are you currently employed?

Yes

Other (please specify)

9. If currently employed, what is the name of your employer?

10. How did you hear about The ALS Association - WI Chapter?

Neurologist

Primary Care MD

Other health care professional

Website - ALS Chapter or ALS National

Referral from ALS National Office

Media

Other

Other (please specify)

11. Are you a veteran?

Yes

12. If yes, have you registered to receive Veteran's Benefits?

Yes

Other (please specify)

13. What is your primary insurance coverage?

Medicare

Medicaid

Private

No insurance

Other (please specify)

14. When were you diagnosed with ALS? (approximate date)

15. Name of MD who provided diagnosis.

16. Are there any members of your family who have ALS?

Yes

17. If so, please state their relationship(s) to you:

18. Please provide name, address and phone of current Neurologist.

19. Please provide name, address and phone of your Primary MD.

20. Additional information or comments.

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The ALS Association Wisconsin Chapter
2505 North 124th Street, Suite #105
Brookfield, WI 53005

(262) 784-5257 Office
(414) 817-1541 Patient Services
(262) 784-5260 Fax