BAMF Health Alzheimer’s Program Inquiry Form

Thank you for your interest in exploring treatment for Alzheimer’s Disease at BAMF Health. The first step is scheduling a consultation. Our consultations help determine whether you are a candidate for imaging and therapy.

Please fill out this form and someone from our team will be in touch!

Please Enter your Name:*

What state do you reside in?*

Select or enter value

Please enter your Date of Birth*

If you have an email address, please enter it here:

Please enter your phone number:*

Street Address*

City State Zip Code*

Primary Insurance Provider*

Secondary Insurance Provider

Enter this field if applicable

Please respond Yes or No to the questions below

Has your doctor diagnosed you with mild cognitive impairment (MCI) or early-stage/mild Alzheimer’s disease?*

Yes

Have you or your family noticed recent memory issues or changes in cognitive abilities, such as forgetting recent conversations or appointments?*

Yes

Are you able to carry out daily activities on your own, like managing medications, paying bills, or preparing meals, even if they take a little longer than before?*

Yes

Send me a copy of my responses

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