Quality of Life Health Care Professional Assessment Form

Save my progress and resume later | Resume a previously saved form

Resume Later

In order to be able to resume this form later, please enter your email and choose a password.

Your Email:

A Password:

Confirm Password:

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 msnavigators@mscanada.ca.

Section A. Quality of Life Equipment Program Applicant Information

Please complete this section providing information on the individual you are doing the Health Care Professional Assessment Form on behalf of (i.e., person applying to the Quality of Life Equipment Program).

First name:

Last name:

Address:

City:

Province/Territory:

Postal code:

Phone number:

Email:

Section B: Health Care Professional Contact Information

First name:

Last name:

Title:

Affiliated organization or business:

Phone number:

Email:

Pronouns (Check one or more options for the set(s) of pronouns you would like us to use in communicating with you):

If you selected Other, please enter pronouns:

Section C: Health Care Professional Assessment

List the equipment you are applying for

Describe the equipment that you are prescribing (e.g., ankle brace, walker, scooter, air conditioner, etc.).

How will the equipment that you are prescribing specifically improve one or more of the applicant’s MS or allied disease symptoms?*

Describe how this funding and equipment would support and benefit the individual and family (e.g., quality of life, independence, etc.).

I can confirm that the applicant has been diagnosed with MS and or an allied disease.

YesNo

I can confirm that the individual has not already ordered and/or paid for the equipment or cooling product for which they are requesting funding.

Yes, I can confirm the equipment has not been ordered or purchased No, the applicant has already purchased or ordered the equipment I do not know

To the best of my knowledge, I confirm this assessment to be accurate and free of errors.

YesNo

To submit the Health Care Professional Assessment Form at this point please click on the submit button.

Save my progress and resume later | Resume a previously saved form

Contact Information