Cooling Vest Application

Anyone living with Fabry disease may apply. Completion of this application allows FSIG to assess need and allocate available vests. Submission of an application does not guarantee receipt, but all applications are carefully reviewed.

First Name

Last Name

Email

Phone

Address 1

Address 2

City

State/Province

Zip

Birth Date

// (mm/dd/yyyy)

Gender

Are you of Hispanic, Latino, or Spanish origin?

No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican American, or Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin
Prefer not to answer

Race

American Indian or Alaska Native
Asian
Black or African American
Middle-Eastern North African
Native Hawaiian or Other Pacific Islander
White
Prefer not to answer

Year of Diagnosis

Where were you diagnosed (State/Hospital Name/Medical Professional Name)

Fabry Type

Fabry Treatment

Your Current Fabry Doctor

Fabry Doctor's Hospital or Clinic Name and Phone

Cooling Vest Measurements

(for ordering purposes)

Chest size

Waist size

Hip size

Let's make sure you are human!

Timeout Warning

Cooling Vest Application

Cooling Vest Measurements