Patient Letter Mailing Request

This form submits a request to produce individual letters to be mailed to a doctor's patients via that doctor's office. Please be specific in this request, upload or email the content that should be included in both the letters and the package, and make sure to follow up with the doctor's office following confirmation of receipt to ensure letters are processed and mailed.

Name of Person Filling Out Form: *

Contact Info for Person Filling Out Form: *

Total Number of Letters Required: *

Doctor's Name and Title: *

Package Contents: *

Patient Letters

Thank you Note to Doctor (provide content in comments section)

Wristbands

Brochures

NephCure Folder

NephCure In Action Packet

5 General Brochures

5 FSGS Brochures

5 Nephrotic Syndrome Brochures

5 Minimal Change Brochures

2 MN Brochures

1 NEPTUNE Brochure

Patient referral form

Questionnaire

Upload Letter:

Upload Additional Flyer/Content:

Return Address for Letter Envelopes: *

This is the address of the doctor's office that should be printed on the return labels of the patient letters.

Comments: *

Package Recipient's Name: *

Recipient Contact Info : *

Recipient Mailing Address: *