Apply for Assistance

Full Name*

Date of Birth MM/DD/YYYY

Email*

Phone Number*

Mailing Address

Preferred Contact Method: (Phone / Email)*

Have you been diagnosed with Charcot-Marie-Tooth disease? (Yes / No)

Type of CMT (if known):

Name of your neurologist or treating physician:

Contact information for your doctor:

Briefly describe how CMT affects your mobility:

Are you applying for: (Check one)

Bracing

Surgery

Have you previously used braces for CMT?

Yes

No

Have you been evaluated by an orthotist?

Yes

No

If yes, provide the orthotist’s name and contact info:

Have you consulted with a surgeon?

Yes

No

If yes, provide the surgeon’s name and contact info:

What procedure has been recommended?

Do you have health insurance?

Yes

No

Does your insurance cover any part of bracing or surgery?

Yes

No

Unsure

Estimated out-of-pocket cost for requested treatment:

Briefly explain why financial assistance is needed:

How would receiving funding for braces or surgery impact your daily life?

Is there anything else you’d like us to know about your situation?

How would receiving funding for braces or surgery impact your daily life?

I certify that the information provided is accurate to the best of my knowledge.

I understand that submitting an application does not guarantee funding.

I agree to allow Cure CMT to contact my medical provider for verification, if needed.

I give permission for Cure CMT to follow up on my progress after receiving funding.

If approved I will submit a testimonial (written or video) of my experience with Cure CMT funded bracing or surgery.

Signature:

Date:

Comments

This field is for validation purposes and should be left unchanged.

Apply for Assistance

Cure CMT Funding Application

Thank You!