AffloVest Giveaway Application

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Email *

Are you a registered participant in BreatheStrong+? (only those who are active registered participants will be considered) *

Yes

Applicant's Full Name
*

Birthdate:
*

YYYY

CF Clinic Name
*

CF Clinic City and State
*

CF Clinic coordinator or social worker name:
*

CF Clinic email address
*

Tell us how an AffloVest would help you better manage your CF and other aspects of your life.
*

Has your insurance denied you for this type of treatment in the past?
*

Yes

Partially

Please share any additional information regarding insurance coverage or copays that would otherwise make an AffloVest out of reach.

By submitting, if you are selected, you agree to be captured in photographs and video, and to allow BreatheStrong CF, Tactile Medical , AffloVest and any other sponsors to utilize your name, photographs, video and story for promotion of the program and BreatheStrong CF fundraising efforts.
*

I agree

I understand that AffloVest recipients must obtain a physician's prescription for the AffloVest airway clearance therapy, a regulated medical device.
*

I understand.

Are you willing to fundraise for BreatheStrong CF? *

Yes

Maybe

Submit

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