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Request an IBD Buddy
1.
What is your age?
16-18
19-24
25-34
35-44
45-54
55+
2.
Are you male or female
Male
Female
3.
Do you have Crohn's or Colitis?
Crohn's
Ulcerative Colitis
Other (please specify)
4.
Have you had surgery?
Yes
No
Other (please specify)
5.
Do you have an ileostomy or colostomy?
Yes
No
Other (please specify)
6.
Are you taking medication that needs to be injected or administered as an infusion?
Yes
No
Other (please specify)
7.
How long have you had IBD?
Just diagnosed
less than 2 years
2-4 years
5-10 years
more than 10 years
Other (please specify)
8.
What characteristics are important to you that your buddy has:
Similar age
Same sex
Had surgery
Has ileostomy/colostomy
On medication that needs to be injected or administered as an infusion
Other (please specify)
9.
What is your availability like?
Mornings
Afternoons
Evenings
Weekends
Other (please specify)
*
10.
Please leave your name, number and email address below and we will contact you!
(Required.)