Covid-19 Response Application to receive 2 Cases of Continence Products

Alzheimer’s of Central Alabama (ACA) is a local organization that provides education, services, advocacy, and research for caregivers and patients living in the 21 counties across central Alabama.  The heart of what we do is helping families keep their loved one at home.     

This program is for people who have Alzheimer’s of a related dementia who require continence care.  ACA can provide 2 cases of continence products (with gloves and wipes if available).  The products will be shipped to your home.

Continence Products
Address for shippping (no P.O. Boxes)
Address for shippping (no P.O. Boxes)
City
State/Province
Zip/Postal
Does the patient have a diagnosis of Alzheimer’s disease or dementia?
Caregiver Address (if different than patient)
Caregiver Address (if different than patient)
City
State/Province
Zip/Postal
You May Choose One of the following
What size (if ordering pullups or diapers). Our office can help you determine correct size if needed.
Do you receive continence supplies from any of the following? Check all that apply:
Please check the sources of income for ALL adults living in the home:
What category best describes the yearly total household income before taxes of ALL adults in the house?
How hard is it for you to pay for the very basics like food, housing, medical care, and heating? Would you say it is:
I verify that all information contained in the application is correct and valid.