Quality of Life Application

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Before starting or completing an application please review and carefully read the Quality of Life Equipment Program Guidelines found on the MS Canada website. This application can be used to apply for new or used equipment, repairs and cooling products (Air Conditioning). 

You may begin and save your progress on the application at any time, by using the save function located at the top of the page. To submit your application, all fields marked with an asterisk (*) must be completed; incomplete sections will prevent the application from being submitted. Please ensure you’ve uploaded all supporting documentation, including the Heath Care Professional Assessment and Vendor Quotes. 

Should you have any questions about the application or program, or are experiencing issues with the application, please contact an MS Navigator at 1-844-859-6789 or msnavigators@mscanada.ca
Section A. Applicant Information

Designated Contact Person for Applicant

Section B: Household Income

Section C: Funding Request 

New or Used Equipment and Equipment and Repair

Please indicate the other source(s) of funding you have or plan to apply for and the amount requested/received:

Repair only

Cooling Product

Health Care Professional Assessment 
A detailed written assessment by the appropriate Health Care Professional (HCP) is required. You may either have your health care professional complete the Health Care Professional Assessment Form (PDF, online version or provide a letter). Please provide the name and information of HCP completing this assessment. 

Section D: Waivers, Disclaimers and Consent 

The above-mentioned request if funded by the MS Society is the property of the applicant for as long as it is required. The MS Society is not responsible for maintenance and/or repairs. Funding is provided on the condition that the MS Society is not held responsible for any damages, claims or causes of action that might arise with respect to the equipment. 

The Multiple Sclerosis Society of Canada protects your privacy. The information provided in this form will be entered into our services database. The information will be used to provide you with the best services, to provide information about our programs and services and to compile anonymous statistical information. The information in this application form is shared with authorized individuals and companies outside the MS Society of Canada on a need to know basis, in relation to this application. By completing and submitting this form you hereby consent to the collection, use and disclosure by the MS Society of Canada of your personal information for these purposes.

If you have any questions about your personal information, or the MS Society's privacy policy and procedures please contact our Privacy Officer, at priv@mssociety.ca or phone 1-800-268-7582.

I understand that the MS Society of Canada provides no cost products (“supports”) to people affected by MS or allied disease who would otherwise be unable, due to financial hardship, to afford those supports on their own. 

To submit the application at this point please click on the submit button.