Psoriasis Cure Now
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Submit Your Personal Psoriasis Story
Want to educate the public about psoriasis and inspire other patients by being in the 2009 Psoriasis Cure Now Patient Calendar? Submit your story here and we will get back to you shortly. Remember that we can only profile 12 people in the calendar but will try to find other ways to involve those we are not able to include in the 2009 edition. Before you submit this form, be sure first to read and understand the Official Rules.


 

All fields are required and must be filled in.


FIRST NAME:

ADDRESS 1:

CITY:

EMAIL:

AGE:

YEAR DIAGNOSED:

LAST NAME:

ADDRESS 2:

STATE:

ZIP:

PHONE:



PSORIASIS TYPE: (check all that apply)
Plaque    Guttate    Inverse    Pustular    Erythrodermic    Psoriatic Arthritis    Not sure   


PERSONAL PSORIASIS STORY (copy & paste into text box below):


 


SUBMIT PERSONAL PHOTOGRAPH
This photo will NOT be used in the calendar. It is for our internal purposes only. It need not be a big or high-resolution photo. Attach photo by clicking the button below:

YES, I have read the Official Rules and Agree to the Terms.


  


 

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