CSRF Patient Advisory Committee Form

Thank you for your interest in learning more about our Patient Advisory Committee. Please complete the form below and we will contact you with more information.

Question Title

* 1. General Contact Information

Name *

Street Address *

City/Town *

State/Province (if applicable)

ZIP/Postal Code

Country (2-letter abbreviation) *

Email Address *

Phone or WhatsApp

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* 2. In what year were you born? (enter 4-digit birth year; for example, 1976)

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* 3. How did you hear about CSRF?

Internet search

Doctor referral

Fellow patient

Other (please specify)

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* 4. Date of diagnosis? (if applicable)

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* 5. Are you interested in sharing your Cushing's story on our website or in a future issue of our Newsletter?

Yes, please contact me

No, not at this time

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* 6. What areas would you like to participate in the Patient Advisory Committee? (You may select more than one)

Ambassador for your community (ethnic, geographic, religion, other)

Website/Newsletter

Social Media Posting or Content

Fundraising Projects

One-time Projects (variety of topics)

Provide Feedback/Insight When Needed

Other (please specify)

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* 7. Comments or feedback

When you submit your form, expect a response within a week. Thank you! If you don't hear back, please contact
leslie@csrf.net for questions or more information.