Respiratory Care Info Card Request Form
Please ensure that you enter the correct US, Canada, UK, South Africa, India, Australia, France, Netherlands, Ireland, Germany, Sweden, Iceland, Philippines, or New Zealand residential mailing address. 

If you have any questions/concerns, please email us at Info@BreathewithMD.org.

At Breathe with MD, Inc., we respect your privacy. The information you share below is used only for the pulse oximeters program and is stored securely. It is only seen in its entirety by one volunteer of our organization. Your information will NOT be shared outside of our organization.
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Do you reside within the United States (US), Canada, the United Kingdom (UK), South Africa, India, Australia, France, Netherlands, Ireland, Germany, Sweden, Iceland, Philippines, or New Zealand?

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Which Neuromuscular Disease (NMD) have you or your loved one been diagnosed with or is strongly suspected? Forms of NMD include Muscular Dystrophy, Spinal Muscular Atrophy, Congenital Myopathy, or other conditions under the "MDA USA umbrella of muscle diseases."

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Do you understand that this card will only be relevant to someone living with a Neuromuscular Disease (NMD)? Note: If you have any other breathing condition, this card will be of no relevance or use to you.

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Required

Full name of individual requesting Respiratory Care Info Card

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How many cards are you requesting?

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What is an e-mail address that is checked regularly?

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Please re-type the e-mail address.

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What residential mailing address should we send the card(s) to? Please be sure to include the FULL address, and if located outside of the United States of America, include the country and any details required for international mail.

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Would you like to get our monthly e-mail updates about events, happenings, and tips related to breathing muscle weakness in Neuromuscular Disease (NMD)? 

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