Jewish Digest IBD Buddy Form
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Email *
Name, First and Last:
I would like to... *
What is your age? *
Are you male or female? *
Do you have Crohn's or Colitis? *
If you would like to specify something about your IBD:
If you would like, indicate the severity of your condition:
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Have you had surgery for IBD? *
If you had surgery and would like to specify:
Do you have an ileostomy or colostomy? *
If you have an ileostomy or colostomy and would like to specify:
Are you taking medication that needs to be injected or administered as an infusion? *
If you are taking medication and would like to specify:
How long have you had IBD? *
Would you like to request a buddy of similar age / gender? Please indicate any other requests and we will do our best to accommodate you.
Please fill out your contact information below:
This information is for Jewish Digest so we can contact you. Your information is strictly confidential – we will not pass on or share your details with anybody else. Once we have found a match for you, we will confirm with you as to how and when you prefer to be contacted by your buddy.
Name *
Phone number *
Email *
What is your availability like? *
What is your preferred method of communication? *
Thank you for signing up with Jewish Digest!
A copy of your responses will be emailed to the address you provided.
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