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STEP 1: V.I.P. Veteran Entry Form Step 1 of 3
After Submitting Step 1, please continue to Steps 2 (Waiver) & Step 3 Intake Meeting
Name
*
First Name
Last Name
Phone
*
-
Area Code
Phone Number
E-mail
*
example@example.com
Date of Birth
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
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31
Day
Please select a year
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
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2012
2011
2010
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1922
1921
1920
Year
Mailing Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Height
*
Weight
*
Disability Rating % if Applicable
Are you a Pre or Post 9/11 Veteran? (Does not determine candidacy but assists in adjunct VSO support facilitations when necessary)
*
Pre 9/11
Post 9/11
How Did You Hear About V.I.P.
*
Internet Search
V.I.P. Veteran
VA Facilitator
Personal Referral
V.I.P. Physician
Other
Please Select All Forms of Service That Apply.
*
Army
Navy
Air Force
Marines
Coast Guard
Special Operations
Green Beret
SEAL
Combat Wounded
Airborne
Medic
MP
Counter Terrorism
Chemical Waste Specialist
EOD Technician
Other
Years of Service
*
ie 1995-2010
Approximate Year Symptoms Commenced
Are You Cancer Free
*
I Have Active Cancer
I Am Cancer-Free
Please Select The Areas of the Body Effecting Your Quality of Life which you would like to address
R Knee
L Knee
R Hip
L Hip
Lumbar Spine
Thoracic Spine
Cervical Spine
R. Shoulder
L Shoulder
R Elbow
L Elbow
R Hand
L Hand
R Ankle
L Ankle
R Foot
L Foot
Migraines
TBI
PTS
Burn Pit / Toxic Exposure
Other
Please list which MRIs you have obtained within the previous year
In order to facilitate a physician consult, MRI(s) of the affected area(s) must be accessible
Please list areas of concern in order of importance from greatest to least
*
Household Income
Less than $40k
$40k to 100k
$100k to $200k
Over $200k
Companion Contact:
Prefix
First Name
Last Name
Relationship to Applicant
Email
example@example.com
Phone
-
Area Code
Phone Number
Have you experienced any of the following? Select all that apply.
Arachnoiditis
RSD/CRPS
MS
ALS
Cancer
Depression
Neurological condition
Anxiety
Liver Disease
Blood Clots
Muscle Dystonia
Paralysis of the upper limbs
Paralysis of the lower limbs
Paralysis of one arm
Paralysis of one leg
Alodynia (unusual sensory reaction to hot or cold)
Chronicly cold feet/toes
Gradual loss of motion in effected limb post-injury
The sensation of burning skin around effected area
Spinal Injury
Spine surgery
Fireball sensation in the spine
Gradual yet repetitive contractions within your spinal cord
Numbing of the hands or feet
Asymmetric weakness and loss of mobility over time (ie: right arm, then left leg)
Loss of appetite
Diabetes
Headaches
Unusual hair growth around injury
Anemia
TBI
Amputation of limb(s)
Phantom pain
Pain levels of 10+
Sensation of water dripping down legs
Sciatica
Legs “fill with cement” upon walking for a period of time
Phantom pain
Numb toe(s)
Numb finger(s)
Migraines
Spinal headaches
Change in vision
Anorgasmia
Insomnia
None of the Above
Spinal Stenosis
CRPS/RSD
MS
Lyme Disease
Rheumatoid Arthritis
Diabetes I or II
High Blood Pressure
Heart Disease
Dystonia (Weakening of the limbs)
Alodynia (exaggerated response to sensory such as heat or cold on skin)
Toxic Exposure / Burn Pit
Other
(Are You Taking Taking immunosuppressives? (This includes but not limited to: Calcineurin Inhibitors: Tacrolimus and Cyclosporine Antiproliferative agents: Mycophenolate Mofetil, Mycophenolate Sodium and Azathioprine
*
Yes
No
Are you able/willing to travel for treatment if necessary?
*
Yes
No
📍THIS IS A CORE ASPECT TO YOUR ENTRY! How has your sacrifice in quality of life affected your life, and that of your family?
*
This is essential to our ability to share the personal aspect of your story in your Veteran Summary which we submit to your potential physician match.
Please Upload an Image or File of Your Official State or Government ID
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All Information Collected is Off-Record
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Please Upload an Image or File of Your DD214
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All Information Collected is Off-Record
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Please Share an Image of You and or Your Family to Personalize Your Application
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All Information is Off-Record
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File Upload Option
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File Upload Option
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File Upload Option
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Origin of Condition(s)
*
Training
Combat
Active Duty
Gradual Degeneration over Time
Other
📍I understand that although V.I.P. Physicians and Specialists provide their professional services through Veterans In Pain at no cost, I understand I am responsible for any 'hard-cost' expenses for procedure(s) I may receive, at a fraction of usual and customary billing practices. 📍I understand V.I.P. provides access to approved VSO's on the V.I.P. Fiscal Foxhole page, to which I may submit my case for funding. 📍Additionally, I am never obligated to undergo a procedure for which I am approved through any V.I.P.- facilitated consultation due to funding related issues, or otherwise.
*
Yes
No
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