Fields marked with an * are required.

First Name *

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Last Name *

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Phone Number *

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Email *

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Date of Birth MM/DD/YYYY *

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Zip Code or Postal Code *

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Have you been diagnosed by a doctor with IgA Nephropathy? *
A common kidney condition that occurs when a certain antibody builds up in the kidneys, affecting their ability to properly filter waste. Please select one... Yes – I have been diagnosed with IgA Nephropathy No

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Have you had a kidney or renal biopsy, to confirm your diagnosis of IgA Nephropathy, in the past 8 years?
A kidney biopsy is a procedure to remove a small piece of kidney tissue that can be examined under a microscope for signs of damage or disease. Please select one... Yes No Unsure

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Have you been told by a doctor that you have proteinuria (an excess of protein in your urine)? * Please select one... Yes No Unsure

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Have you ever had a kidney transplant, also called a renal transplant or kidney replacement surgery? *
A kidney or renal transplant is a surgery done to replace a diseased kidney with a healthy kidney from a donor. Please select one... Yes No

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Have you been diagnosed by a doctor with any other medical conditions? *
Please list here or write 'none'.
Please only include conditions that have been diagnosed by a doctor.

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Are you taking any medications for your IgAN or because your doctor told you that there is protein in your urine (known as proteinuria)? * Please select one... Yes No

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Are you taking any medications for your IgA Nephropathy (IgAN) or other health conditions? *
Please list them below or type ‘none’.

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Please, select your height from the dropdown below. * Please select one... 4'0" 4'1" 4'2" 4'3" 4'4" 4'5" 4'6" 4'7" 4'8" 4'9" 4'10" 4'11" 5'0" 5'1" 5'2" 5'3" 5'4" 5'5" 5'6" 5'7" 5'8" 5'9" 5'10" 5'11" 6'0" 6'1" 6'2" 6'3" 6'4" 6'5" 6'6" 6'7" 6'8" 6'9" 6'10" 6'11"

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How much do you weigh in Lbs (pounds)? *

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Are you currently participating in a clinical trial for an investigational drug or device? * Please select one… Yes No

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Would you be willing to participate in this study for a period of 3 years? *
Keep in mind that participation is entirely voluntary. If you do decide to take part in the study, you may change your mind about participating at any time. Please select one... Yes No I don't know - I need more information from the Study Team

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If female, are you currently pregnant, or breastfeeding? Please select one... Yes No N/A - Male

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Would you like to be contacted about taking part in a Clinical Study? *

Yes

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What is the best day/time to reach you via telephone? *

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