—Please choose an option—Mr.Ms.Mrs.Dr.Rev.
—Please choose an option—AlaskaAlabamaArkansasArizonaCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMichiganMinnesotaMissouriMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWisconsinWest VirginiaWyomingDistrict of Columbia
Are you willing to have your contact information shared with fellow Patient Ambassadors?*
Yes, you may share my contact information.No, you may not share my contact information.
We encourage Patient Ambassadors to work together. If you are comfortable consenting to sharing your information, we would like to provide your contact information to your fellow Patient Ambassadors in your state or region to help you coordinate. We will not provide any of your information to third parties or anyone outside DPC and the Patient Ambassador program.
Which of the following best describes you?*
—Please choose an option—In-Center HemodialysisHome HemodialysisPeritoneal DialysisFamily MemberTransplant RecipientChronic Kidney Disease (Pre-Dialysis)
Are you bringing a family member/friend/caregiver?*
Are you vegetarian?*
Is your guest vegetarian?*
Are you gluten-free?*
Is your guest gluten-free?*
Where would you like to be picked up?*
—Please choose an option—ChicagoJolietI am taking care of my own transportation to Springfield.
Do you have any needed accessibility accommodations that we should be aware of? If so, describe in the box below:
Emergency Contact Information
Emergency Contact Name*
Emergency Contact Number*
Emergency Contact Relationship*
1012 14th St NW, Suite 1475 Washington DC, 20005
Dialysis Patient Citizens
Dialysis Patient Citizens (DPC) is the nation’s largest patient-led organization working to improve the quality of life for dialysis patients. Join us in making a difference for those with kidney disease by enrolling as a DPC member today. (Membership is free.)
We need your help to remind policy makers that we are real people and not just a line-item in their budget. You can make a huge impact by calling, emailing, or writing to share your story with your elected officials.
Act now to ensure your voice is heard, and to sign-up so that we keep you up-to-date on the issues that impact you and your family.