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/
Primary Institution Name*
Institution Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email
Specialty*
- Adult Nephrology
- Pediatric Nephrology
Practice Setting*
- Private Practice
- Academic
Headshot
Max. 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.