FDRS Conference Form

Email*

First Name*

Last Name*

Role*

Credentials

MD

NP

PA

PhD

PT

PTA

OT

COTA

CLT

RN

DO

LMT

Other

Professor

CMT

LPN

LANA Certified

DPM

AT

RMT

Board Certified Plastic Surgeon

Certified Wound Specialist

MBA

MS

MLD-C

RDN

LD

Post-Doc

ABPS

Affiliated Organization*

Please enter the clinic, hospital, or company name where you practice.

Do you diagnose Lipedema?*

Do you treat Lipedema?*

City*

If not in the US, please type n/a

State (of Residence)*

I have a personal connection to Lipedema.

I wish to join your mail list and agree to receive certain electronic communications (or other communications applicable to the contact information that I have provided) from you (such as brochures, newsletters and other promotional content), in accordance with your Privacy Policy, which I have read and acknowledged.

I agree to receive other communications from Lipedema Foundation.

I understand and acknowledge that you will treat the information provided by me via the forms above in accordance with your Privacy Policy, which I have read and acknowledged. Our privacy policy can be found at www.lipedema.org/privacy-policy.

I agree to allow Lipedema Foundation to store and process my personal data.*

You can unsubscribe from these communications at any time. For more information on how to unsubscribe, our privacy practices, and how we are committed to protecting and respecting your privacy, please review our Privacy Policy.