VIP Veteran Entry Form

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 NameLast Name
Phone*

Area CodePhone Number
E-mail*
example@example.com
Date of Birth*

MonthDayYear
Mailing Address:*

Street Address

Street Address Line 2

CityState / 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 9/11Post 9/11
How Did You Hear About V.I.P.*

Internet SearchV.I.P. VeteranVA FacilitatorPersonal ReferralV.I.P. PhysicianOther
Please Select All Forms of Service That Apply.*

ArmyNavyAir ForceMarinesCoast GuardSpecial OperationsGreen BeretSEALCombat WoundedAirborneMedicMPCounter TerrorismChemical Waste SpecialistEOD TechnicianOther
Years of Service*
ie 1995-2010
Approximate Year Symptoms Commenced
Are You Cancer Free*

I Have Active CancerI Am Cancer-Free
Please Select The Areas of the Body Effecting Your Quality of Life which you would like to address

R KneeL KneeR HipL HipLumbar SpineThoracic SpineCervical SpineR. ShoulderL ShoulderR ElbowL ElbowR HandL HandR AnkleL AnkleR FootL FootMigrainesTBIPTSBurn Pit / Toxic ExposureOther
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 $200kOver $200k
Companion Contact:

PrefixFirst NameLast NameRelationship to Applicant
Email
example@example.com
Phone

Area CodePhone Number
Have you experienced any of the following? Select all that apply.

ArachnoiditisRSD/CRPSMSALSCancerDepressionNeurological conditionAnxietyLiver DiseaseBlood ClotsMuscle DystoniaParalysis of the upper limbsParalysis of the lower limbsParalysis of one armParalysis of one legAlodynia (unusual sensory reaction to hot or cold)Chronicly cold feet/toesGradual loss of motion in effected limb post-injuryThe sensation of burning skin around effected areaSpinal InjurySpine surgeryFireball sensation in the spineGradual yet repetitive contractions within your spinal cordNumbing of the hands or feetAsymmetric weakness and loss of mobility over time (ie: right arm, then left leg)Loss of appetiteDiabetesHeadachesUnusual hair growth around injuryAnemiaTBIAmputation of limb(s)Phantom painPain levels of 10+Sensation of water dripping down legsSciaticaLegs “fill with cement” upon walking for a period of timePhantom painNumb toe(s)Numb finger(s)MigrainesSpinal headachesChange in visionAnorgasmiaInsomniaNone of the AboveSpinal StenosisCRPS/RSDMSLyme DiseaseRheumatoid ArthritisDiabetes I or IIHigh Blood PressureHeart DiseaseDystonia (Weakening of the limbs)Alodynia (exaggerated response to sensory such as heat or cold on skin)Toxic Exposure / Burn PitOther
(Are You Taking Taking immunosuppressives? (This includes but not limited to: Calcineurin Inhibitors: Tacrolimus and Cyclosporine Antiproliferative agents: Mycophenolate Mofetil, Mycophenolate Sodium and Azathioprine*

YesNo
Are you able/willing to travel for treatment if necessary?*

YesNo
📍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 Cancelof
Please Upload an Image or File of Your DD214

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Please Share an Image of You and or Your Family to Personalize Your Application

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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)*

TrainingCombatActive DutyGradual Degeneration over TimeOther
📍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.*

YesNo
Thank you for reaching out to our team at V.I.P.
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STEP 1: V.I.P. Veteran Entry Form Step 1 of 3