Suffolk County In-Person Lupus Support Registration

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Thank you for your interest in our Suffolk County Lupus Support Group! Please complete this form to notify our facilitators, Jeanine & Ken Cox, Jacqueline McClean, Jessica Washington, and share some information about yourself.

First and Last Name *

Email Address *

Phone Number

City *

State *

What is your lupus connection? *

I might have lupus.

I am newly diagnosed with lupus (within 2 years).

I have lupus.

I am a lupus caregiver/care partner for a family member.

I am supporting a friend with lupus.

I am a medical provider.

Other

I lost a loved one due to lupus.

If you have lupus, what type of lupus were you diagnosed with?

Systemic Lupus (SLE)

Discoid “Skin” Lupus (DLE)

Lupus Nephritis (LN)

Central Nervous System Lupus (CNS)

I have not been diagnosed with lupus.

I am not sure.

N/A

Please share any topic(s) you'd like this group to discuss.

Submit

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