NephCure Specialist Nomination Acceptance Form Please complete the following form with your preferred contact information for your listing on NephCure’s KidneyHealthGateway.com. Please note that this is the information that will appear on the website and inform patients how to reach out to you to schedule appointments, so please only include information you don’t mind being publicly listed online. Visit the NephCure Specialists page on Kidney Health Gateway to see how other specialists have listed their information. Name* First Middle Last Post-Nominal (MD, PhD, MPH, etc.) Pronouns* Please write your personal pronouns in the box above. Examples: She/Her, He/Him, They/Them, Ze/Hir, No Pronouns - Use My Name. Learn more here: https://www.mypronouns.org/what-and-why/Race/Ethnicity* Please describe your race/ethnicity in the box above. Examples: White, Black/African American, Asian, Native Hawaiian or Other Pacific Islander, Hispanic/Latino, etc.Gender Identity*MaleFemaleTransgender manTransgender womanNonbinary/Gender DiverseGenderqueerPrefer not to answerOther (gender identity not listed)Gender Identity (choose the option that best reflects your identity)If you answered 'Other (gender identity not listed)', please specify. Primary Institution Name* Institution Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone*Email Specialty* Adult Nephrology Pediatric Nephrology Practice Setting* Private Practice Academic Concentration*We want to ensure we are sending patients to the best possible physician for their condition. What do you consider your concentration? For example: Focal Segmental Glomerulosclerosis (FSGS), IgA Nephropathy (IgAN), Minimal Change Disease (MCD), C3 Glomerulopathy (C3G), MPGN, Nephrotic Syndrome, Alport Syndrome, Transplant, etc.HeadshotMax. file size: 50 MB.Please upload a headshot to be included on the website. If a headshot is not provided, we will use a publicly-available image (found on your institution website).Preferred website link E.g. your personal page on your institution's/practice’s website, your LinkedIn page, etc. If a page is not provided, we will link to the most appropriate publicly-provided page. Δ