The Missy Project

11303 Dead Oak Lane.  Austin, Texas 78759
512-257-9680  Fax:512-335-4166
www.themissyproject.com
marymagel@sbcglobal.net

 

The Brain and Spine Center is conducting a Community
Screening Program together with The Missy Project
for Research of Early Detection of Brain Aneurysms.

Application for Community Screening Program
January-December 2009

 
 
Name:
eMail Address:
Address:
City:
State:
Zip:
Day Phone:
Evening Phone:
Mobile Phone:
Family Physician:
Address:
City:
State:
Zip:
Office Phone:

I would like apply for a free screening of an MRA for early detection of brain aneurysm disease
provided by The Missy Project and the Brain and Spine Center at Brackenridge Hospital, Austin, TX.

I am 16 years of age or older

AND

I have two (2) family members (primary; mother, father, sister, brother or secondary; grandmother, grandfather, aunt or uncle) who
has had a brain aneurysm.

AND/OR

I have one (1) primary or secondary family member who has had a brain aneurysm AND who has hypertension OR who is a smoker.

I agree to undergo the process required to participate including:

** Provide documentation re: first degree relative
** Participate in Telephone Screening Discussion w/ Lauren Brandt, Clinical Director of the Brain and Spine Center.
** Sign Consent Screening Form
** Have MRA
** Have a follow up meeting with a staff member of the Brain and Spine Center to discuss results of MRA and any
risk factors associated with Brain  Aneurysm Disease.

  
  _______________________________   _______________    
   
Name
     
Date
      
                   
  Please fill out form and fax to 335-4166 or mail to address above.  In an effort to
expedite qualification, you can send in your application and provide medical documents
at a later date.  For more information about this screening program, please contact
Mary Magel, Executive Director of The Missy Project at 512-257-9680.