Participant Interest Form

If you live with Hidradenitis Suppurativa and would like to be matched with an experienced Buddy who can support you, then complete the form below to send us your information.

Interested in becoming a Buddy and helping others? Then you are in the wrong place - please apply to become a Buddy here instead.

Sign up here to be matched with an experienced Buddy who can support you:

*First Name

*Last Name

*Email Address

*Phone Number

Text messaging
Your Buddy can stay in touch with you by text message as well as by email. If you'd like to text with your Buddy, enter your cell phone number below.

Cell Phone

I agree to receive text messages from HS Buddies and my Buddy at this number. Message and data rates may apply. You can reply STOP at any time to stop receiving texts.

*Time Zone

*Address

Address Line 2 (Apt, PO, Suite, etc)

*City

*State

*Zip

*Birth Month

*Birth Day

*Birth Year

*Ethnicity

*Race

*Gender

*Education

*Occupation

*Income Level

*Primary Language

*Referral Source

*Where did you hear about us?

Check this box if you have a confirmed diagnosis of Hidradenitis Suppurativa.

Treating Physician Name

Treating Physician Facility

Check this box if you are currently enrolled in a clinical trial.

Check this box if you are interested in enrolling in a clinical trial.

What qualities are you looking for in a buddy? (i.e. male/female, specific race/ethnicity, specific sexual orientation, approx. age, etc.)

Do you have any goals or key discussion topics you want to address with your Buddy at some point in your sessions? If nothing comes to mind at the moment, you can always address this later with your Buddy.

Share a brief description of your HS Journey so far. (limit to 1000 characters)

Sign up here to be matched with an experienced Buddy who can support you:

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