Contact Us Form

 



 
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I would like more information about:
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 Support Groups (in person or online) 
 Clinical Trials 
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 Lupus Aware Physician List 
 Financial, Co-Pay or Prescription Assistance Resources 
 General Lupus Information 
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 Walk to End Lupus Now 
 Hosting a Fundraiser or Event 
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 Lupus Now Magazine 
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Please provide any additional information that we should know in order to help support you better:
 

 

 
How did you hear about us? *
 Internet Search (google, yahoo, etc.) 
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 LFA FL Chapter (website, infoline, etc) 
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 Word of Mouth 
 TV/Radio/Newspaper 
 LFA National 
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 Lupus Now Magazine 
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For Lupus Patients Only

The following questions are for those living with lupus.
What type of lupus were you diagnosed with?
 
What year were you diagnosed?
ex: 1999

If you are contacting on behalf of a lupus patient...

 
Patient's name
 
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First
 
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