Dercum's Friendly Provider Survey

FDRS in conjunction with Dercum's Disease Answers is compiling an international directory of Dercum friendly providers - providers who are helping manage your care. They need not be specialists, simply providers (doctors, nurses, PAs, therapists) who are or who have become familiar with Dercum's, has shown you compassion and care, and who has helped you along your journey.

Please provide as much information as possible. Only the items with an asterisk are required.

Submit a different entry for each provider if you have more than one.

Together, with your help, our goal is to provide a network of providers locally who are Dercum's Aware!

Thank you in advance for your participation.

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* 1. Provider's First Name

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* 2. Provider's Last Name

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* 3. Type of provider

Doctor (MD, DO, ND)

Advanced Practice Provider (PA, NP, DNP)

Therapist (PT, OT, CLT, LMT, PTA, OTA)

Other (please specify)

Dercum's Friendly Provider Survey

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* 1. Provider's First Name

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* 2. Provider's Last Name

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* 3. Type of provider

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* 4. City

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* 5. State

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* 6. Phone # (ex. 5555551212 numbers only, no dashes or spaces)

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* 7. Website (if known)

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* 8. How has this provider helped you?