AGREEMENT
I would like to submit a story
Full Name
*
First Name
Last Name
Best Contact Email
*
example@example.com
Best Contact Phone Number
*
Your phone number
Format: (000) 000-0000.
Who are you?
*
Tell us who you are
Where are you from?
*
Where you live
I agree not to identify any healthcare professional or healthcare organization by name in my story, unless I have their written permission to do so.
*
YES
NO
I agree not to identify any patients or their lay caregivers by name, unless I have obtained their written permission to do so.
*
YES
NO
I agree that PFPS US can take reasonable steps to verify the accuracy of my story.
*
YES
NO
I agree to work with PFPS US to develop this story in a way that ensures accuracy.
*
YES
NO
Please Sign Below
*
Submit
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