NephCure Information Form First Name of Person Completing This Information Form: Last Name of Person Completing This Information Form: What is your relationship to the patient? Choose from list or select "Other" and enter details below: --None--SelfParentOther Other relationship: Patient's Street Address: City: State/Province: Zip Code: Country: Preferred Phone: Preferred Email: Patient's First Name: Patient's Last Name: Patient's Date of Birth: Please select the ethnicity with which the patient most closely identifies. May select more than one option. If Other, please see next question: American Indian or Alaskan NativeAsianBlack or African AmericanHispanic or LatinoNative Hawaiian/Other Pacific IslanderWhite, not HispanicOther Other race/ethnicity with which patient identifies: What is the patient's diagnosis? Please select one option from the list or enter different diagnosis in the "Other" area: Nephrotic SyndromeMinimal Change Disease (MCD)FSGSMembranous NephropathyIgM NephropathyIgA NephropathyMPGNCongenital Nephrotic SyndromeLupus NephritisDiabetic NephropathyAlport SyndromeC1q Nephropathy Other Diagnosis: What year was patient diagnosed: How did you first hear about the NephCure Foundation? Please select from the list or choose "Other" and enter your answer: --None--Internet SearchFriend and/or Patient Medical ProfessionalFacebookTwitterNephSpaceInspire.comMediaPublication How did you hear - other: Do you access the NephCure Foundation Facebook page: --None--YesNoWould you like to receive information on: Our ongoing research efforts? NephCure educational programs? Connecting with other patients and families within our community? NephCure Walks and other events?Would you like to receive educational materials/brochures on any of the following diseases?Would you like to make a difference and help the NephCure community in any of the following ways? (Please feel free to make other suggestions in the comments section below.) Thank you for taking the time to help us learn more about how we can help you. Please use the space below for any additional comments, questions, or suggestions that you may have: Send me a copy * These fields are required.