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* 1. First Name

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* 2. Last Name

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* 3. Email

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* 4. Why do you donate to NANOS? Please share your testimonials below by telling us why you support and donate to NANOS and help us tell OUR story to a bigger world. Your story is NANOS's story.

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* 5. Check one of the boxes below to indicate whether you give NANOS permission to use your donor testimonial and/or name in our fundraising campaigns (on social media channels, website, and in other marketing materials).

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* 6. If we were to tell the NANOS story to the lay audience and solicit donations from your patients, which slogans would resonate with your patients (e.g. Help NANOS fight MS, NMO, IIH, MG, NAION, Help NANOS give a louder voice to patients in need of neuro-ophthalmic care, other).

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