Patient's Age:
Patient's Location:
Which Section of the Pen Pal Circle do wish to be added? Survivor
Family or Friend of Survivor
Family or Friend of Loved One Lost to ARDS
In Crisis
Reason for Hospitalization? Sender's Relationship to Patient: (If self, please enter "self") Sender's Name Email Address (required) Please tell us what you would like to see posted on the Pen Pal Circle page: (note: This may be edited for space requirements) Do you wish to receive our Weekly Newsletter? YES NO Please check yes or no giving us permission to publish your email address on the website.YES NO
Reason for Hospitalization?
Sender's Relationship to Patient: (If self, please enter "self")
Sender's Name
Email Address (required)
Please tell us
YES
NO
Please check yes or no giving us permission to publish your email address on the website.
