73-710 Fred Waring Dr.

Suite 120 A
Palm Desert, CA 92255

Tele: 760.773.9806
Fax:
760.406.6137

actforms@verizon.net



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      Please download/print these application forms, fill them   out and mail them to our office. After our office receives and reviews your application you will be notified if we can assist       you with our many programs.        

                    - Application for Assistance   

                         - Liability Release   

                 - Neurologist Release  

                 - Neurologist Verification 

                 - Client Program Questionnaire