Patient Registration Inquiry

We’re here to help. ALS United Mid-Atlantic supports people living with ALS, their families, and caregivers throughout our region. Please complete the form below so our care services team can better understand your needs and connect you with the appropriate resources, programs, and support.

"*" indicates required fields

Name*

First Last

Date of Birth

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Name of Doctor Who Diagnosed You

Name of Hospital/Healthcare Facility/ALS Clinic Where You Were Diagnosed

Primary Phone*

Primary Phone Type*

Secondary Phone

Secondary Phone Type

Email*

CAPTCHA

If you or a loved one is newly diagnosed with ALS, you are not alone. ALS United Mid-Atlantic is here to help you understand your options and connect with supportive ALS resources across our region. By completing this new patient inquiry form, you allow our care services team to learn more about your needs and reach out with guidance, education, and personalized support. We assist people living with ALS and their families with care coordination, equipment loan programs, support groups, and trusted referrals.

Our team understands that the early days after a diagnosis can feel overwhelming, and we are committed to providing clear information and compassionate support every step of the way. The information you share will be kept private and used only to connect you with helpful ALS care services and community resources.