Virtual Community Meetings Registration

Please fill out and submit this one-time registration to access the ILD Collaborative Virtual Community Meetings. We will review your submission and get back to you shortly.

First Name *

Last Name *

Email *

Are you a patient or caregiver? *

Patient

Caregiver

When were you (or when was the person you care for) diagnosed with an interstitial lung disease (ILD)? *

Month

Day

Year

How did you learn about the ILD Collaborative? *

What are reasons for joining the ILD Collaborative Virtual Community Meetings? Please check all that apply *

To connect with other patients and caregivers living with interstitial lung disease

To increase my understanding of interstitial lung diseases

To find ways to improve my or my caregiver's quality of life living with interstitial lung disease

To enroll into a clinical trial to further research in interstitial lung disease

To increase awareness and share resources with my health care providers and community

Other

Are you (or is the person you care for) actively being followed for interstitial lung disease by a health care provider? *

Yes

If Yes, please check all that apply

Primary Care Provider (PCP)

Local Pulmonologist

ILD Specialist at an academic institution

How far do you (or does the person you care for) currently drive to see your (his/her) ILD Specialist? *

Less than 50 miles

50 to 100 miles

Greater than 100 miles

Other