Physician Directory Registration

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If you would like to be in our Physician Directory that we make available to lupus patients, please fill out this form.

First Name*

Last Name*

Suffix

Phone Number at which Patients Can Reach You*

Address, line 1*

Address, line 2

City*

State*

Zip Code*

Email Address (Email addresses will only be used for communication between the physician and the LFA, GOC.)*

Hospital Affiliation

Specialty

The Lupus Foundation of America, Greater Ohio Chapter is always looking for physicians willing to write a brief newsletter article or present at a chapter meeting on a particular aspect of lupus. Please indicate if you are so interested.

I am interested in writing an article.

Yes No

I am interested in presenting.

Yes No

I am interested in being on the medical advisory board.

Yes No

Submit

By submitting this form, you give permission to the Lupus Foundation of America, Greater Ohio Chapter, Inc. to release and distribute the provided information. (The LFA, GOC will not distribute email addresses to patients.)