Medical Community- Materials Request Form

Request some of FSR’s informational materials for a patient event or for regular distribution to patients being seen at your clinic.

Disease Overview Brochure

Patient Registry Postcard

FSR Resources half-pager

What is Sarcoidosis? half-pager

Your Name*
First Last
Title(s)*
MD, LPN, clinic coordinator, etc.
Email*
Phone*
Hospital Affiliation*
Specialty/Department*
Shipping Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Is this for a specific event or for regular distribution to patients?
- Specific event(s)
- For regular educational use
Tell us about the event:
Please include a short description of the event you're requesting materials for.
Date by which you need to receive materials
MM slash DD slash YYYY
How many sarcoidosis patients does your institution treat?
Please estimate the annual volume of sarcoidosis patients seen at your clinic annually.
Type of materials requested*
- FSR Education and Research goals (1-page flyer)
- What is Sarcoidosis? (1-page flyer)
- Patient Registry Cards
- Disease Overview Booklet
Notes:
Include any additional notes you think our team might need to know.

Your compare list