Brighter Tomorrow Grant DOCTOR’S CONFIRMATION FORM In order to process your grant application, we are required to have verification of your MS diagnosis on file. Please have your doctor sign this confirmation form and stamp with the doctor’s office information. Alternately, the doctor may provide written verification on letterhead stating that you have been diagnosed with MS. (Please note: if you have submitted a doctor’s confirmation to MS Focus within the last two years, please call to confirm whether your prior confirmation is sufficient.) Applicant’s Name: (Please print name) ( Sign) Address: Phone: Email: Doctor’s Name and Address Stamp: Phone: Fax: Important: Doctor’s Signature Required. I can confirm that this patient has been diagnosed with multiple sclerosis. (Doctor’s Signature) (Date) All information obtained will be held in strict confidence and we will respect your privacy. National Headquarters: 6520 North Andrews Avenue, Fort Lauderdale, Florida 33309-2132 National Toll-Free Helpline:888-673-6287 • Fax: 954-351-0630 support@msfocus.org • www.msfocus.org