You will be contacted via email once you have completed all steps of the application process.*If you do NOT have a lymphedema diagnosis, please do not fill out questionnaire. Mother's Name * First Name Last Name Father's Name First Name Last Name Child's Name First Name Last Name Child's DOB Child's Gender Male Female Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone # (###) ### #### Email Mother's Occupation Father's Occupation Annual Household Income Number of people living in household? 1 2 3 4 5 6 7 8 9 10 Primary Language Do you have health insurance? Yes No Explain your current financial situation and why you are requesting help. How did you hear about Brylan's Feat Foundation? What areas are affected by lymphedema? What lymphedema treatment (s) are you seeking help with? Is there a family history of lymphedema? Does your child have any other medical conditions? At what age did your child show signs of lymphedema and at what age was it officially diagnosed? How were they diagnosed (ultrasound, lymphoscintigram, etc.) and by whom? Is your child currently seeing a CLT (certified lymphdema treatment)? Have they received proper CDT (complete decongestive therapy)/ reduction phase including short stretch bandaging? What is the current treatment plan, if any, and is it consistent? I know that if my application is not completed (uploaded documents, questionnaire, signed responsibility form and signed photo authorization) within 3 days, my application is subject to denial. Brylan's Feat Foundation will not contact you regarding assistance until your request is submitted. Yes, I understand I understand that failure to comply with treatment may result in discontinuance of assistance for care. Yes, I understand I understand that it is my responsibility to follow up with Brylan's Feat Foundation when new treatments are needed and that proof of compliance might be requested. Yes, I understand Thank you!
