Please Provide Contact Information So We May Follow Up With You

 
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GLBTQ Legal Advocates & Defenders (GLAD) is conducting this survey as part of the Treat Lipodystrophy Coalition. GLAD understands the need for confidentiality. All information provided will be held in the strictest of confidence. We ask for contact information so that we can follow up with you about your experience. If you have questions about your situation or anything in this survey, please contact the GLAD Legal InfoLine at 800-455-GLAD or www.glad.org/rights. At the end of the survey, you will be directed to more information about the work of the Treat Lipodystrophy Coalition. Your story is very important to us. Thank you!

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* 1. Name

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* 2. Email Address

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* 3. Phone Number

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* 4. City or Town

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* 5. Age

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* 6. Gender

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