The Oley Foundation Membership Form

All Oley services and educational materials are FREE for consumers and their caregivers.
If you would like to make a tax-deductable contribution click here.
Please note: if you have already donated using the donate now button
on our home page this will be a second donation.

Knowing this information will help Oley network consumers more effectively and better raise money for programs like the LifelineLetter, Toll-Free Hotline, Annual Conference, and RC Network !
* These are required fields to submit the membership form

New Membership  

Membership Renewal (check here to update your membership information)

1. Contact Information (please print clearly)
* Consumer/Patient Name
Caregiver Name (if applicable)
* Address
Address2
* City * ST * Zip
* Phone Fax
* E-mail

2. How Did You Hear About Oley?
Internet/WWW Discharge Planner Homecare Company
Physician/Nurse Friend/Family Member Other

3. Consumer/Patient Information
Date of Birth
Sex Male Female
Began HomePEN Therapy
Therapy HPN Enteral Tube-fed Both

Medical History
4. Diagnosis/Primary Reason for HomePEN
AIDS (279.19)
Cancer
Chronic Adhesive Obstruction (560.81)
Congenital Bowel Defect, at birth (751.5)
Crohn's Disease (555.9)
Ischemic Bowel Disease, mesenteric infarct (557)
Malabsorption (579.9)
Malrotation of the Gut (751.4)
Motility Disorder, pseudo-obstruction (564.8)
Physical Trauma or Accident (759.8)
Radiation Enteritis (558.1)
Swallowing Disorder Stroke (436)
Ulcerative Colitis (556)
Other

Is your colon in continuity? Yes No
Approximate length of residual bowel

Have you ever been transitioned (HPN to HEN or HEN to HPN)?
Yes No

5. Do You Want To Communicate With Other
Consumers?
YesNo

6. If an opportunity to participate in a research study arises, are you willing to be contacted by an investigator?
Yes No

7. What topics would you like additional information on?
Insurance Legislation Travel tips Pain Management
Caregiver Issues Human Interest Stories Coping Transplant
Pediatric Issues Diarrhea Therapy Complications
Other

8. Send me the LifelineLetter via Email? (Email copies arrive sooner and reduce Oley's postage costs)
Yes No

9.  Interested in meeting other patients? Check out the "Meet Patients" section of our website which features regional volunteers with their contacting information , phone volunteers just a toll-free call away,  our chat forum and patient profiles.

10. Who is your homecare provider?

American Home Patient
Apria Healthcare
Coram Specialty Infusion Services
Home Medical of America
Nutrishare
ThriveRx
Walgreens
 
Other Company Name
Company Phone
 

11.  Send information to my clinician at:

 


Complete one or both sections depending on your nutritional needs

TPN Consumers

11. Type/Brand of Catheter (Check one type and maker)
Catheter Type
Implanted Port GROSHONG ®  Catheter HICKMAN ® Catheter BROVIAC ® Catheter
Cook CatheterPICC Line
Other

Manufacturer
ArrowBecton-Dickinson C.R Bard Cook Critical Care. B.Braun/McGaw Deltec
Other

12. Brand of Pump (Check one or more as applicable)
Sabratek (i.e. Sabratek 6060, 3030 etc.)
Abbott Labs. (i.e. Abbott AIM, Provider One)
Deltec (i.e. CADD)
Curlin
Other Brand Name

EN Consumers

11. Type/Brand of Tube (Check one type and maker)
Tube Type
G-TubeJ-TubeButton Other
Manufacturer
RossBallardBardOther

12. Do you Use a Low Profile Device?
Yes          No

13. Brand of Pump (Check one or more as applicable)
Abbott Labs (i.e. Companion, Flexiflo, Patrol)
Kendall Healthcare (i.e. Kangaroo, Kangaroo Pet )
Moog (i.e. Enteralite, EnteralEZ, Infinity)

Other Brand Name

14. Brand of Formula (Check one)
Abbott  (i.e. Ensure, Osmolite, Jevity, Pediasure, etc.)
Nestlé (i.e. Replete, Peptamen, Vivonex, Complete, Isosource etc.)

Other Brand Name

15.  Market Research (Would you be willing to take part in research in your area either in person or online?)
 Yes          No

Note:  HICKMAN ®, BROVIAC ®, and GROSHONG ® are registered trademarks of C.R.Bard, Inc and its related company BCR, Inc.