non-scoliosis Application

* Indicates required field

Applicant Name *

First

Last

Email *

Phone Number *

Patient Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Hardship Letter *

Max file size: 20MB

Personal Letter of Recommendation *

Max file size: 20MB

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? *

Align Scoliosis FoundationFinancial Support Application for NON-scoliosis bracing( other orthotic and prosthetic devices )

Align Scoliosis Foundation
Financial Support Application for NON-scoliosis bracing
( other orthotic and prosthetic devices )