Jewish Digest IBD Buddy Form
Sign in to Google to save your progress. Learn more
Email *
Name, First and Last:
I would like to... *
What is your age? *
Are you male or female? *
Do you have Crohn's or Colitis? *
Required
If you would like to specify something about your IBD:
If you would like, indicate the severity of your condition:
Clear selection
Have you had surgery for IBD? *
If you had surgery and would like to specify:
Do you have an ileostomy or colostomy? *
If you have an ileostomy or colostomy and would like to specify:
Are you taking medication that needs to be injected or administered as an infusion? *
If you are taking medication and would like to specify:
How long have you had IBD? *
Would you like to request a buddy of similar age / gender? Please indicate any other requests and we will do our best to accommodate you.
Please fill out your contact information below:
This information is for Jewish Digest so we can contact you. Your information is strictly confidential – we will not pass on or share your details with anybody else. Once we have found a match for you, we will confirm with you as to how and when you prefer to be contacted by your buddy.
Name *
Phone number *
Email *
What is your availability like? *
What is your preferred method of communication? *
Thank you for signing up with Jewish Digest!
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy