Associate/Patient Groups One-Pager Information

Thank you for being such a vital part of our community. Your contributions are greatly appreciated.

We would be honored if you would take a few minutes to complete the following form. The information you provide will be used to create a one-page document that highlights your organizaton and the resoruces you offer.

Thank you in advance for your time
Organization Name*
Email Contact
example@example.com
Web Address
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Organization Phone Number
Please enter a valid phone number.
Disease Your Organization Represents
Who You Serve

0/45
Organization Vision

0/45
Organization Mission

0/45
How your condition IMPACTS patients

0/65
Organization Story/About/History

0/55
How you organization makes an impact

0/150
How your organization provides support at a glance

0/40
Upload your Logo Here

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Upload up to 2 images of individuals affected by your skin condition.

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Would you like to include a QR Code on your One Pager?

Yes, I will upload one our organization has.Yes, I need one created for our organizationNo
Upload QR Code

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Provide a link, for QR Codes to be added to your one-pager
Enter Your Social Media Handles
Should be Empty: