Request to Participate in a Lupus Research Study

Please provide your contact information.

Name
Work Phone
Home Phone
E-mail

Please enter some statistical information.

Date of Birth
Sex	Female Male

Which of the following best describes you?

African-American
Asian American
Hispanic
Native American
White
Other

If you have been diagnosed with lupus, how many years have you had lupus?

If you do not have lupus, and are interested in being a control in a study, please check here:

  Yes

Select any disease you have.

diabetes	heart disease	cancer
nephritis	thyroid disease	high blood pressure
arthritis	kidney disease	osteoporosis
raynaud's	vascular disease	neuropathy	other

May we send you information periodically?

no
yes

Any comments or other information you want to include?

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