Patient and Care Partner Story Collection
Are you interested in impacting your community to make a difference? Take action and use your voice to shine a light on kidney disease. Are you currently on dialysis? Or have you received a successful transplant, but used to be on dialysis? We'd love to hear your story and hear about your kidney journey. Please fill out this quick interest form, and we will be in touch to follow up with you!
Full Name
*
Dr.
Miss
Mx.
Mr.
Mrs.
Ms.
Prefix
First Name
Last Name
Suffix
Contact Phone Number
*
Please enter a valid phone number where you can be reached.
Email Address
*
example@example.com
Your connection to kidney disease
*
Please Select
I am at risk for kidney disease
I have CKD Stage 1 or 2
I have CKD Stage 3
I have CKD Stage 4 or 5 and not on dialysis
I am on dialysis
I am a transplant recipient
I have kidney cancer
I have kidney stones
I am the care partner / family member of a kidney patient
Current treatment
*
N/A - I am no longer on dialysis
Home Hemodialysis
Hemodialysis
Peritoneal Dialysis
Dialysis Type Unknown
I received a pre-emptive kidney transplant
I received a transplant from a living donor
I received a transplant from a deceased donor
Type a question
Type option 1
Type option 2
Type option 3
Type option 4
Where do you live?
*
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
What is generally a good time to call you to learn more about your story? Please select all timeslot(s) M-F that are best for you.
*
8:00 - 10:00am
10:00 - 12:00pm
12:00pm - 2:00pm
2:00pm - 4:00pm
4:00pm - 6:00pm
Monday
Tuesday
Wednesday
Thursday
Friday
Please note here anything specific about your availability that you'd like us to know.
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Demographics
Please help us to ensure that we are collecting kidney stories that will represent all of those impacted by kidney disease. NKF collects demographic data on people who use our programs in order to measure our reach, impact and effectiveness in different communities.
Gender: How do you identify? (Optional)
Please Select
Female
Male
Non-binary
Prefer to Self Describe
Gender: Please self-describe
How would you describe your ethnicity? Please select all that apply.
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Prefer not to answer
Other, please describe.
Please select your age range: (Optional)
Under 18
18-24
25-39
40-55
55-64
65-80
80+
Prefer not to answer
Please share any additional details about your story / journey / experience that you'd care for us to know.
Submit
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