Cushing’s Support & Research Foundation Membership Application

Contact Information * denotes required field

Name *

Date

Address *

City, State, ZIP*

Home Phone

Work Phone

FAX

E-Mail Address *

Membership Level

I would also like to purchase the Special Newsletter for an additional $20.00 (enclosed)
yes no

Are you a:

May the CSRF provide your name and phone number to patients that contact us? yes no

May the CSRF provide your email to patients who contact us? yes no I don't have email

Would you like to be contacted by other CSRF members? yes – by email yes – by phone no

Would you like your name, city, state, tumor location, phone and email listed in our next newsletter
so others may contact you? yes no

Date of Birth MM-DD-YYYY

PRIVACY
If you do not want to answer any of the following
questions, please leave blank.

Occupation current former

Tumor Location/Source of Cushing’s

Age at Diagnosis

Month/Year Diagnosed MM-YYYY

How long did you have Cushing’s before diagnosis months

How many physicians did you see before diagnosis

Who originally suggested Cushing’s as your diagnosis

Transphenoidal surgery yes no When Where

Adrenalectomy Unilateral Bilateral When Where By Laparoscopy

Radiation: Traditional Gamma knife Lineac When

Have you had a pituitary tumor recurrence yes no

2nd Surgeries (please give details)

Other

Have you been told that you have any of the following:

Diabetes Insipidus	Hypopituitary or Total pituitary removed
Diabetes	Growth Hormone deficiency
Nelson’s Syndrome	Thyroid Hormone deficiency
Osteoporosis	Female Hormone deficiency
Adrenal Hormone deficiency	Male Hormone deficiency
Other – please describe

Have you been tested for Growth Hormone deficiency? yes no

Do you take Growth Hormone? yes no

Do you take DHEA? yes no

How did you hear about the CSRF?

What would you like the CSRF to do for you?

Was your family supportive? yes no

Are you interested in volunteering? yes no

Would you recommend your doctor to a patient seeking diagnosis/treatment of Cushing’s? yes no

If yes, who is your current endocrinologist (or primary doctor if not an endocrinologist)?
This doctor will receive a complementary copy of our newsletter.

Name

Specialty

Address

City, State, Zip

Phone

If you would like a complimentary newsletter sent to additional doctor(s) or family members please complete the following
(all information, including zip code, must be included):

Name

Specialty

Address

City, State, Zip

Phone

Please attach send us an Email for additional doctors, your story,
questions for our Medical Advisory Board, and any other comments.cushinfo@CSRF.net

Value

After clicking "Submit" you will be redirected to PayPal for your payment information.

Thank You for Your Support!

CSRF - 65 E India Row, Suite 22B - Boston, MA 02110