Cooling Vest Application

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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

Phone

Address 1

Address 2

City

State/Province

Zip

Birth Date

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

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