First Name
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Last Name
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Email
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In which State/Territory do you live?
VIC
NSW
QLD
NT
TAS
WA
SA
ACT
Mobile Phone
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Additional Informations
Can you tell us what the current kidney condition is, of you or the person you’re caring for
On haemodialysis
On peritoneal dialysis
Living with a transplant
Stage 1-3 of kidney disease
Stage 4-5 of kidney disease
Are you someone living with kidney disease or caring for someone with kidney disease?
Person living with kidney disease
Parent/carer/family of someone with kidney disease
Which renal unit or hospital do you attend for management of your condition?
What peer support are you interested in learning about from your Kidney Buddy?
Have you received any kind of support from us previously, or been involved in some capacity:
Kidney Health Australia website
Social media (e.g. Facebook, Twitter)
Email
Renal unit
My healthcare professional
Fellow patient/carer
Support group
How did you hear about the Kidney Buddies?
Kidney Health Australia website
Social media (e.g. facebook, twitter)
Email (e.g. newsletter)
Renal unit
My healthcare professional
Support group
Fellow patient/carer
I wish to receive Your Kidney Connection newsletter