Membership Application


Member Information

Salutation: Mr. Mrs. Ms.
First Name:
Last Name:
E-Mail:
Address:

City:
State:
Zip Code:
Phone:

Optional Information

You are not required to provide these data but it will assist the Association in developing important information regarding the Association's members.

  1. Your age:
  2. How long have you been on supplementary oxygen based on a physician's prescription?
    Years Months
  3. How many hours per day do you use oxygen?
  4. Do you use stationary equipment?
    If so, which system(s) do you use?
    Liquid     Concentrator
  5. Do you use portable equipment?
    If so, which system(s) do you use?
    POC (Portable Oxygen Concentrator)     Liquid tanks     Compressed gas tanks
  6. What is your primary diagnosis warranting oxygen usage?
  7. May we include your name and contact information in our user to user Information Exchange Directory?
    Yes     No
  8. How did you hear about NHOPA?

NHOPA Membership Fees:

Payment

Please mail this form with your check to NHOPA at the address below:

Make check payable to:
NHOPA
8618 Westwood Center Drive, Suite 210
Vienna, VA 22182-2222

Inquiries:
NHOPA Executive Office
8618 Westwood Center Drive, Suite 210
Vienna, VA 22182-2222
1-888-NHOPA-44