Share Your Story of Life as a Patient

Please consider telling us about your story of life as a patient with FSGS and Nephrotic Syndrome. Your submission authorizes NephCure to publish the story and photo on our website and in other materials. NephCure reserves the right to make edits, but will get back to you with revisions before it is published. Therefore, we need accurate and complete contact information.

Submit your Video Story - If you would rather submit a video story, please post your video to YouTube and then e-mail the link to gwiley@nephcure.org. We will post the story on NephCure.org and share it on the NephCure YouTube channel.

Patient First Name: *

Patient Last Name: *

Gender: *

Female

Male

Date of Birth: *

Please format Month / Day / Year (example: 6/21/2011)

Patient Disease: * select...Focal Segmental Glomerulosclerosis (FSGS)Minimal Change DiseaseNephrotic Syndrome

Please select one

Age at Time of Diagnosis: *

Tell Your Story: *

Please submit your story not to exceed 500 words.

Please Send Your Photo:

Please submit a high resolution image of the patient, between one and two megabytes (1-2 MB) in size. That way, it can be used in print or online. You may submit a gif, jpg or png.

Who is Submitting this Story?: *

Tell us if you are the patient or a member of their family (i.e., mother, father, brother, sister, cousin, aunt or uncle).

Email Address: *

Phone : *

What is your Facebook page?:

What is your Twitter handle?:

CAPTCHA

This question is for testing whether you are a human visitor and to prevent automated spam submissions.