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Join the APF: Online submission

NEW Members:

Please complete the following form to join the American Porphyria Foundation. After you complete this form, please follow the instructions on the next page to send your membership donation to the APF. Annual membership is $35 for members who live in the US, $45 for international members.

Thank you!

* Required

Prefix:
First Name*
   Last Name*
Address*
City*
     State*
     ZIP*
Country*
Phone Number*
   Alternate Phone
Birthdate
E-mail Address

Which of the following best describes you?
Healthcare professional
Porphyria patient
Family member
Other interested party

Your answers to the following questions will provide very important information and have a direct impact on foundation activities.

1. If you are being treated for porphyria, which type do you have:
ALAD Porphyria (ADP)
Acute Intermittent Porphyria (AIP)
Congenital Erythropoietic Porphyria (CEP) (Gunther's disease)
Porphyria Cutanea Tarda (PCT)
Hepatoerythropoietic Porphyria (HEP)
Hereditary Coproporphyria (HCP)
Variegate Porphyria (VP)
Erythropoietic Protoporphyria (EPP) (Protoporphyria)
I don't know/I have not been diagnosed

2. Would you be interested in volunteering for porphyria medical research?
YES
NO

3. Would you like to receive additional educational material regarding porphyria?
YES
NO

4. What information would you like to see on the American Porphyria Foundation website that is not already there?

5. Would you like to be a member of the In Touch network and be placed in contact with others with your type of porphyria? (If yes, please complete an In Touch consent form and return it to the foundation. Download here)
YES
NO

For educational and clinical research purposes, the APF would like to have contact information for the physician who has primary responsibility for managing your porphyria. The APF will send a comprehensive information package on the diagnosis and treatment of the porphyrias to your physician, if you are a member of the APF.

Please complete the requested information below.

Doctor's First Name
   Doctor's Last Name
Doctor’s Organization/Practice Name
Doctor's Street Address
Doctor's City
     Doctor's State
     Doctor's Zip
Doctor's Phone Number
  Doctor's Fax Number
Doctor's E-mail Address

 

Privacy reminder:

The American Porphyria Foundation is committed to maintaining the security of your information.

We will only collect information about you if you voluntarily provide it to us. We will use this information to better understand our members, and the data will only be shared with our advisors and APF members. Your information, including your email address, will never be sold to any other third party organization under any circumstances without your consent unless required by law. You may remove yourself from this list at anytime by contacting the APF.