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

*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.)

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

Participant Interest Form

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

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