The ALS Association Western Pennsylvania Chapter: Survey - Patient Services Quick Registration

Patient Services Quick Registration

Please fill out the following information so that we can begin to serve you. A member of our patient services staff will be in touch within the next two business days with more information and to answer your questions.

1.

Please provide your contact information.

*

Name:

First Required	Last Required

Email:

*

Street 1: Required

Street 2:

*

City/State/ZIP:

City Required	State Required	ZIP Required

*

Phone Number: Required

*

Date of Birth: Required

Date of Birth:

Month

Day

Year

Yes, I would like to receive e-mail from The ALS Association

Yes, I would like to receive postal mail from The ALS Association

Remember me. What's this?

*2.

Question - Required - Have you been diagnosed with ALS by a physician?

3.

Question - Not Required - Are you a veteran?

4.

Question - Not Required - Are you currently receiving Social Security Disability benefits?

*5.

Question - Required - I would like more information about (select all that apply)...
Please make between 1 and 11 selections from the choices below.

	Veterans Benefits
	In-home Care
	Social Security Disability
	Respite Care
	Transportation
	Assistive Communication Devices
	Equipment/Loan Closet
	Resource/Support Groups
	Multidisciplinary Clinic - Pittsburgh
	Multidisciplinary Clinic - Johnstown
	Nutrition/Supplements

6.

Question - Not Required - Please provide any additional information that you feel would be important to our patient services staff.