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Align
Scoliosis Foundation
Financial Support Application for NON-scoliosis bracing
(
other orthotic and prosthetic devices
)
*
Indicates required field
Applicant Name
*
First
Last
Email
*
Phone Number
*
Patient Name
*
First
Last
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Patient Curve magnitude
*
34º or Lower
35º - 49°
50º or Greater
Age of Patient
*
0 - 3 years old
4 - 11 years old
12 - 18 years old
Do you have other children with current brace treatment?
*
Yes
No
If so, how many?
*
Are you a single parent?
*
Yes
No
Are you a United States Resident?
*
Yes
No
Are you a resident of California, Texas or Wisconsin?
*
Yes
No
Hardship Letter
*
Max file size: 20MB
Personal Letter of Recommendation
*
Max file size: 20MB
A letter from a friend or family member explaining why you are a good candidate.
Are you or a family member coping with any other health issues? If so, please explain:
*
It is recommended that you wear your brace as was prescribed by your MD. Will you:
*
Agree to do this every day
Wear the brace half those hours
Wear the brace the time prescribed a few times a week
Probably won't wear it
Do you currently volunteer, or do you have an immediate family member who does? If so, who and how many hours have you completed in the last 12 months?
*
Average Household Income
*
How did you find out about Align Scoliosis Foundation?
*
Who is the prescribing Medical Doctor?
*
Who is the orthotist providing the brace or if therapy, who is the Physical Therapist?
*
What is the type of brace you are applying for this funding?
*
What is the name of the brace company or if Schroth therapy, what is the name of the company?
*
How much is the cost per session?
*
How many session were prescribed?
*
Submit
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