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I am a stroke survivorI am a caregiverOther
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Thank you for your interest in IpsiHand!

Please reach out to info@neurolutions.com with any questions you may have.

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Stroke survivor date of birth?*

MMDDYYYY
Have you ever tried or are you currently participating in any form of Physical or Occupational Therapy for stroke recovery?*
YesNo
What type of insurance do you have?*
Who is your insurance provider?
Age of Stroke Survivor*
How to take a photo of your insurance card:
- Click “Take Photo” to turn on your camera.
- Hold your insurance card in front of the camera. Make sure all four corners are visible, and the text is clear.
- Click “Take Photo” again to capture the image.
- If needed, click “Retake Photo” to try again.
- Please repeat this process for both the front and back of your card.
Take a Photo of the Front of Your Insurance Card
Take a Photo of the Back of Your Insurance Card
YesNo
When was the stroke?

MonthDayYear
Date
Less than 6 months ago6 or more months ago

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What is Your Name?*

First NameLast Name
City*
State*
Zip Code*
5-Digit Zip Code
Email*
example@example.com
Address

Street Address

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City

Zip Code
Phone Number*
Please enter a valid phone number.
Is this a Mobile Phone number?*
Yes, I am an eligible veteran.
BY CLICKING “SUBMIT & AGREE” ABOVE, I AGREE THAT I WOULD LIKE NEUROLUTIONS, INC. AND KANDU, INC. TO REACH OUT TO ME TO LEARN MORE AND TO RECEIVE TEXT MESSAGES FROM OR ON BEHALF OF NEUROLUTIONS, INC. AND KANDU, INC. AT THE PHONE NUMBER I PROVIDED ABOVE REGARDING IPSIHAND, MY ELIGIBILITY, AND INSURANCE COVERAGE FOR IPSIHAND. THESE TEXTS MAY BE CONSIDERED MARKETING UNDER APPLICABLE LAW AND MAY BE SENT USING AN AUTODIALER. CONSENT IS NOT A CONDITION OF PURCHASE. MESSAGE FREQUENCY VARIES. MESSAGE AND DATA RATES MAY APPLY.

IF I DO NOT AGREE, I CAN CALL 1-833-813-4774 TO LEARN MORE ABOUT IPSIHAND AND INQUIRE ABOUT ELIGIBILITY.
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