First Name*
 
 
 
Last Name*
 
 
 
Email*
 
 
 
In which State/Territory do you live? 
 
 
 
Mobile Phone*
 
 
 
 
 
Additional Informations
 
Can you tell us what the current kidney condition is, of you or the person you’re caring for
 
 
 
Are you someone living with kidney disease or caring for 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:
 
 
 
I wish to receive Your Kidney Connection newsletter
 
 
 
How did you hear about the Kidney Buddies?