MEMBERSHIP FORM
Please PRINT THIS FORM and complete
the following:
| Name: Address: City/State/Zip: E-mail: Telephone: |
________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ |
Optional Information:
Statistical information is needed to advance the cause of the lymphedema movement. When making the case for insurance coverage, treatment centers and research, statistics are an essential component in the presentation. All information is confidential and would not be used in conjunction with any names.
| What
was the cause of your lymphedema? What was the date of onset? Have you had treatment? When, and at what facility were you treated? Did your insurance cover your treatment? Did your insurance cover your supplies? What was the name of your insurance company? What was the percentage reduction you attained? Is your lymphedema under control? Do you do a home self-care plan Who was your referring doctor and what was his/her specialty? How has lymphedema affected your life |
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ |
Fill out this form and send it along with your tax-deductible contribution of $25.00 to:
Circle
of Hope Lymphedema Foundation, Inc. Federal
ID# 06-1549500
Please make checks payable to: Circle of Hope Lymphedema Foundation, Inc. |
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