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Advocate Signup Forms

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How Can We Reach You?

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If you’d like to, please feel free to fill in these fields. It’s fine if you choose not to – we won’t take offence.

Female

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Are you?

In order to offer you the most relevant tasks and support, we want to know if you are a patient or carer. This information helps us match you with tasks and resources that best suit your situation and experience.

Patient

Carer

Both care and patient

What is home for you?

Urban (Inside a large metropolitan city)

Suburban (Oursite a large metropolitan city)

Countryside (small town from a large metropolitan city)

Year of birth(Required)

We kindly ask you to enter your year of birth. This helps us to assign you the most relevant tasks, as some tasks have specific age requirements.

Where are you from?

Middle Eastern

White/Caucasian

Native Hawaiian

Pacific Islander

Asian

American Indian or Alaska Native

Black/African American

Hispanic/Latino

By sharing your health experience with us, we can process your confirmation faster. At the same time, it allows us to identify future opportunities that could be relevant to you, if you wish.

What disease areas are you interested in?

This information helps us match you with tasks and resources that best suit your situation and experience.

Cardiovascular Disease

Cardiovascular disease is a broad term for diseases that affect the heart and blood vessels.

Respiratory Diseases

Respiratory diseases are a group of diseases that affect the respiratory tract, which includes the nose, throat, trachea, bronchi and lungs.

Chronic Obstructive Pulmonary Disease (COPD)

Asthma

Pneumonia

Pulmonary Embolism

Sleep disorders (including sleep apnea)

Other lung disease

Gastrointestinal Diseases

Gastrointestinal diseases, also known as gastrointestinal diseases, affect the digestive system, which extends from the mouth to the rectum.

Neurological Diseases

Neurological diseases are disorders that affect the brain, spinal cord and nerves, which together make up the body’s nervous system.

Endocrine Diseases

Endocrine diseases are disorders that affect the body’s hormone-producing glands that make up the endocrine system.

Diabetes Mellitus (Type 1 and Type 2)

Hypothyroidism

Hyperthyroidism

Cushing’s Syndrome

Graves’ disease (hyperthyroidism)

Hashimoto

Hormonal disorders

Overweight/obesity

Other endocrine diseases

Musculoskeletal Diseases

Musculoskeletal diseases encompass a wide range of conditions that affect the body’s muscles, bones, joints, tendons and ligaments.

Psychiatric Diseases

Psychiatric illnesses, also called mental disorders or mental illnesses, are conditions that affect a person’s thinking, emotions, behaviour and overall mental health.

Oncological Diseases

Oncological diseases refer to cancers that occur when cells in the body start growing and dividing uncontrollably.

Renal Diseases

Kidney disease refers to a group of conditions that affect the kidneys, which are vital organs that filter waste products and excess fluid from the blood and produce urine.

Infectious Diseases

Infectious diseases are diseases that occur as a result of infections caused by microorganisms such as bacteria, viruses, fungi or parasites.

Sepsis

HIV/AIDS

Tuberculosis

Bacterial diseases

STDs (excluding AIDS, HIV, HPV, etc.)

Other infections

Translation Crew

Be one of our Local patient-led translations – and YOU can be part of the team! Are you bilingual, have experience as a patient or relative, and want to help make important information available to more people, tick here on your select your language. Help translate texts into your native language Ensure that the language makes sense to patients in your country.

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Important Information

By completing this form, you consent to receiving information and materials related to our initiatives, including patient engagement activities, research studies, and other relevant opportunities. Your personal information will be processed in accordance with our privacy policy. You can read our full policy here, and you may withdraw your consent at any time by contacting us the unsubscribe link in our emails. At PiCC United, we are committed to ensuring that everyone is fairly compensated for their time and contributions. However, please note that in some cases, compensation may not be possible. Even so, your involvement remains vital in driving meaningful change.

Join Our

Interest List

Advocate Signup Forms

Next Steps: Sync an Email Add-On

How Can We Reach You?

What disease areas are you interested in?

Important Information

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