Street Address

City, State, Zip

A peek into the life of a 24 week MIcro preemie - from the NICU and beyond.

MEDEK Intensive Request form

Parent's Name

First Name

Last Name

Child's Name

First Name

Last Name

Child's age

Child's current weight

Child's diagnoses

Child's current abilities

Cell Number

Country

(###)

###

####

Intensive Location

Do you have any MEDEK Equipment?

Set of boxes

Treatment Table

Leg immobilizers

No equipment

No equipment, but willing to purchase

intensive week availability and/or special schedule requests

Willing to host? (if applicable)

How many sessions per week would you prefer?

10 sessions per 5 days is max (2 sessions per day)

Instagram Name

Do you have facebook?

Private facebook groups are used to coordinate some of the details on intensives.

Yes

Message