CHICAGO COMPASSION CLUB ONLINE APPOINTMENT REQUEST FORM

* Denotes required fields.
You must complete all fields before submitting the form.

First and Last Name *

Your Email Address *

Your Telephone Number *

Condition(s) You Were Diagnosed With * YOUR CONDITION MUST BE LISTED ON THE OFFICIAL QUALIFYING LIST (Goto www.chicagocompassionclub.org for listing)

Year of Diagnosis

Name of Doctor Providing Diagnosis *

Doctor's Telephone Number *

Location of Diagnosis (City and State Where You Were Diagnosed) *

Do You Have Radiological Documents? (CT Scans, MRI's) * YES NO

Number of Records * Please use a number

I certify the above information is true and correct * YES

Are You Human? *