EmailMeForm
Information and Support Request Form
We are so happy you found us. Please complete the form below and we will get back to you within 24-48 hours (Monday-Friday). You may also contact us by calling 1-800-90-LUPUS (905-8787) or visiting www.lupusfl.org.
First Name
*
Last Name
*
Company
Address
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Antigua and Barbuda
Aruba
Bahamas
Barbados
Belize
Canada
Cayman Islands
Cook Islands
Costa Rica
Cuba
Dominica
Dominican Republic
El Salvador
Grenada
Guatemala
Haiti
Honduras
Jamaica
Mexico
Netherlands Antilles
Nicaragua
Panama
Puerto Rico
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Trinidad and Tobago
United States
Argentina
Bolivia
Brazil
Chile
Colombia
Ecuador
Guyana
Paraguay
Peru
Suriname
Uruguay
Venezuela
Albania
Andorra
Armenia
Austria
Azerbaijan
Belarus
Belgium
Bosnia and Herzegovina
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Estonia
Faroe Islands
Finland
France
Georgia
Germany
Greece
Hungary
Iceland
Ireland
Italy
Kosovo
Latvia
Liechtenstein
Lithuania
Luxembourg
Macedonia
Malta
Moldova
Monaco
Montenegro
Netherlands
Norway
Poland
Portugal
Romania
San Marino
Serbia
Slovakia
Slovenia
Spain
Sweden
Switzerland
Ukraine
United Kingdom
Vatican City
Afghanistan
Bahrain
Bangladesh
Bhutan
Brunei Darussalam
Myanmar
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China
East Timor
Hong Kong
India
Indonesia
Iran
Iraq
Israel
Japan
Jordan
Kazakhstan
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Lebanon
Malaysia
Maldives
Mongolia
Nepal
Oman
Pakistan
Palestine
Philippines
Qatar
Russia
Saudi Arabia
Singapore
Sri Lanka
Syria
Taiwan
Tajikistan
Thailand
Turkey
Turkmenistan
United Arab Emirates
Uzbekistan
Vietnam
Yemen
Australia
Fiji
Kiribati
Marshall Islands
Micronesia
Nauru
New Zealand
Palau
Papua New Guinea
Samoa
Solomon Islands
Tonga
Tuvalu
Vanuatu
Algeria
Angola
Benin
Botswana
Burkina Faso
Burundi
Cameroon
Cape Verde
Central African Republic
Chad
Comoros
Democratic Republic of the Congo
Republic of the Congo
Djibouti
Egypt
Equatorial Guinea
Eritrea
Ethiopia
Gabon
Gambia
Ghana
Gibraltar
Guinea
Guinea-Bissau
Cote d'Ivoire
Kenya
Lesotho
Liberia
Libya
Madagascar
Malawi
Mali
Mauritania
Mauritius
Morocco
Mozambique
Namibia
Niger
Nigeria
Rwanda
Sao Tome and Principe
Senegal
Seychelles
Sierra Leone
Somalia
South Africa
Sudan
Swaziland
United Republic of Tanzania
Togo
Tunisia
Uganda
Zambia
Zimbabwe
Country / Region
County
*
Email
*
Home Phone
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Cell Phone
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I am:
*
Please select
living with lupus
a parent of a child with lupus
a spouse/partner of someone with lupus
a friend/caregiver of someone with lupus
seeking diagnosis
a healthcare professional
other
(please select one)
Patient's Current Age
I would like more information about:
(check all that apply)
*
Lupus Aware Physician List
Support
Educational Programs (seminars, teleconferences, etc.)
General Lupus Information
LFA Events
Walk to End Lupus Now
Hosting a Fundraiser or Event
Volunteering
Brochures
Program/Event Sponsorship
Other
(please select all that apply)
Please provide any additional information that we should know in order to help serve you better:
How did you hear about us?
*
Internet Search (google, yahoo, etc.)
Support Group
Brochure
Healthcare Professional
LFA FL Region (website, infoline, etc)
Event (Walk, Seminar, etc.)
Word of Mouth
TV/Radio/Newspaper
LFA National
Facebook/Twitter/Instagram/Other
Other
What type of lupus?
Systemic Lupus Erythematosus (SLE)
Lupus Nephritis
Discoid (Skin)
Pediatric Lupus
Neonatal
Drug Induced
Seeking diagnosis
Family member/friend
Healthcare professional
Did not wish to disclose
Other
Year of Diagnosis
Which of the following most accurately describe(s) you?
*
Female
Male
Prefer not to disclose
Other
What is your ethnicity?
*
Hispanic
Non-Hispanic
Prefer not to disclose
What race do you most identify with?
*
Black or African American
White
Native Hawaiian or Pacific Islander
Asian
American Indian or Alaskan Native
Prefer not to disclose
Office Use Only
Date Call/Email Received
MM
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DD
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