Before starting or completing the Health Care Professional Assessment Form please review and carefully read the Quality of Life Equipment Program Guidelines
as well ensure you have all the relevant information needed to complete the form. This form is used to provide supporting information regarding a person’s application to the MS Society of Canada’s Quality of Life Equipment Program.
You may begin and save your progress on the form at any time, by using the save function located at the top of the page. To submit the form, all fields marked with an asterisk (*) must be completed; incomplete sections or questions will prevent the form from being submitted.
Should you have any questions about the form or the Quality of Life Equipment Program, or are experiencing issues with the application, please contact an MS Navigator at 1-844-859-6789 or email@example.com