Lupus Navigator Request Form

 


 
Date *

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First Name *
 
Last Name
 
Address
 
Street Address
 
Address Line 2
 
City
 
State / Province / Region
 
Postal / Zip Code
 
Country
 
County
 
Email
 
Home Phone

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Cell Phone

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I am:
 

For Lupus Patients

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 in regards to a lupus patient...

 
Patient's name
 
Prefix
 
First
 
Last
 
Suffix
 
Relationship
 

 

 
I would like more information about: (check all that apply) *
 Support Groups (in person or online) 
 Clinical Trials 
 General Lupus Information 
 Social Butterflies (a lupus meetup) 
 Educational Programs (seminars, teleconferences, etc.) 
 Lupus Aware Physician List 
 Financial or Co-pay/Prescription Assistance Resources 
 Lupus Liaisons (peer-to-peer mentor program) 
 Lupus Materials 
 LFA Events 
 Walk to End Lupus Now 
 Other 
 
 
Please provide any additional information you would like us to know so we can better support you:
 

 

 
How did you hear about us? *
 Internet Search (google, yahoo, etc.) 
 Support Group  
 Brochure 
 Healthcare Professional 
 LFAFL Chapter Website 
 Event (Walk, Seminar, etc.) 
 Word of Mouth 
 TV/Radio/Newspaper 
 LFA National 
 Facebook/Twitter/Other Social Media 
 Lupus Living Magazine 
 Other 
 
 

For LFA Office Use Only

 
Inquiry Type
 
Received by:
 
Referred to: