I give permission to my healthcare or service provider to fax or e-mail my name and contact information to the Alzheimer's Association. I understand that an Alzheimer's Association Helpline representative will contact me about support and educational opportunities. In addition to giving my permission to be contacted by the Alzheimer's Association, I give permission for the Alzheimer's Association to share a summary of our discussion with the referring provider as indicated above. I understand this is a free service provided by the Alzheimer's Association. I understand that my name, contact information or health information listed below will not be disclosed or shared with any other entity unless authorization is obtained by me.
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To be completed by the professional
24/7 Helpline 800-272-3900 / www.alz.org FAX: 314-269-1624