Name:

(Please Print)

Phone# with Area Code OPTIONAL

Full Mailing Address:(Please Print)

E Mail Address:

Are You a       Patient,    Caregiver/Support Person,    Family Member, Friend, Medical/Professional, Other

                             (Please circle One)

How Did you Hear About COPD Canada? (Please circle)     Friend,  Internet Search, Brochure, Link   from Another Site,  Other

(For Canadian Members) It is expected that as a Member of COPD Canada Patient Network you will agree to participate in at least 2 major mail campaigns annually.  These mail campaigns may be to a newspaper, a member of parliament or minister etc. One letter; at least twice a year.  

Do You Agree to This?       Yes         No

(Please Circle One)

(For Canadian Members) We are trying to compile some provincial info re: the coverage of certain meds.

Do you KNOW  if the following medicines are covered in your province within your Pharmacare programs? (Circle all that apply or leave blank if unsure)

Advair,   Spiriva,   Symbicort,   Oxygen

(For Canadian Members) We are also trying to compile a list of  Resources (by province) for Rehab & Support Groups (i.e. Better Breathers groups) for COPDer's even if NOT put on by, or organized by,  the Lung Association.  Are you aware of any in your province?  If Yes; do you know how who and where they’re located?

(A Name, phone # and/or e mail address would be helpful if you're aware of any in your province.)

(For Canadian Members) It is our hope to have a representative in every province.  Currently we have physical representation in only 4 provinces . We are  seeking additional representatives.  It would be expected that you would know, or are willing to find out,  the resources available as it pertains to COPD for your province.  You would ultimately be the "resource person" for that province. 

Is this something you might be interested in? ______