COGI Membership Application

  • Color of Gastrointestinal Illnesses Membership Form

  • Membership Categories

    Patient
    An individual living with a gastrointestinal illness or ostomy who directly receives medical care, treatment, and support services.

    Parent
    A mother, father, or legal guardian who provides care, guidance, and advocacy for a child or dependent living with a gastrointestinal illness or ostomy.

    Patient Care Partner
    A spouse, family member, friend, or trusted caregiver who provides physical, emotional, or decision-making support to a patient living with a gastrointestinal illness or ostomy.

  • Are you the patient, parent, or care partner?*
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  • Community Member Survey

    This section allows COGI to learn more about the nuances of our community and expand our cultural competence.
  • Do you have health insurance?*
  • Do they have health insurance?*
  • What is your preferred learning style for education? Select all that apply.*
  • Do you have difficulties reading or writing?*

  • Diagnosis Survey

    This section allows COGI to record, evaluate, and understand the experiences of patients and caregivers disproportionately affected by digestive illnesses.
  • Have you been medically diagnosed with a condition that qualifies as a disability? Please select all that apply:*
  • Has the patient been medically diagnosed with a condition that qualifies as a disability? Please select all that apply:*
  • Select the GI illness(es) you were diagnosed with? Select all that apply.*
  • Select the GI illness(es) the patient was diagnosed with? Select all that apply.*
  • Do you have a clear understanding of the diagnosis?*
  • Are you interested in a second opinion?
  • Will you travel for a second opinion?
  • Are the symptoms properly managed?*
  • Is there a clear understanding of the medications prescribed?
  • Do you have an ostomy?*
  • Does the patient have an ostomy?*
  • Are you interested in participating in clinical research?*
  • Is the patient interested in participating in clinical research?*
  • Do you want additional information on clinical research?*
  • Do you have family support?*
  • Have you been diagnosed with a mental health condition? Select all that apply.*
  • Have they been diagnosed with a mental health condition? Select all that apply.*
  • Has your digestive illness impacted your mental health?*
  • Has the patient's digestive illness impacted their mental health?*
  • Has your mental health impacted your ability to receive patient care?*
  • Has their mental health impacted their ability to receive patient care?*
  • How is your mental health currently?*
  • How is their mental health currently?*
  • Do you need mental health support?*
  • Do they need mental health support?*

  • Thank you for submitting a membership application and we look forward to supporting you within our community!

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