Inspire Others with Your Story! Submit Your Patient Story SalutationMr.Mrs.Ms.Dr.First Name * Required Last Name * Required Email * Required Address Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Share your name? * RequiredUse my first name onlyI would prefer to remain anonymousPlease let us know how or if you would like your name to appear if we use your story.Share your location? * RequiredYes, it is ok to share my City/StateList my State onlyList my City onlyNo, please do not list my City/StateBy default, we will share the City/State that you provide to us if we use your story. If you would prefer to have your location remain anonymous, please select "No" above.Phone Number We will never share your phone number. It is NOT required. We will only use this phone number if we have a question about your submissionRelationship to patientI am the patientSpouseOther family memberFriendOtherGive your story a title Your Story: Help us define the face of peripheral neuropathy! * RequiredFollow this format to be accepted: Tell us a little about yourself What is your connection to peripheral neuropathy? When and how were you diagnosed with peripheral neuropathy? Who diagnosed your PN? what type of PN do you have? How have you been managing your PN? what’s the number one thing that helps you manage PN the best? What do you wish people knew about PN? What inspires you to face peripheral neuropathy head-on and how do you do it? What advice would you give others going through the same journey? What is your motto to live by? Upload a Photo of the PatientAccepted file types: jpg, pdf, Max. file size: 10 MB.Maximum file size - 10 mega bytes. Upload a photo of the authorAccepted file types: jpg, pdf, Max. file size: 10 MB.Maximum file size - 10 mega bytes. Upload other photos or files Drop files here or Select files Accepted file types: jpg, pdf, Max. file size: 10 MB, Max. files: 3. Maximum file size - 10 mega bytes. Permission to Publish * Required Yes By submitting your story/photo and clicking the checkbox above, you grant the Foundation for Peripheral Neuropathy permission to use your story, photo, first name, and city/state/country (if permission is granted herein) without any compensation to you for as long as the Foundation wishes to do so. The Foundation for Peripheral Neuropathy may use your story in whole or in part in print or promotional materials, on its website, its emails, its social media, or its communications. We will never publicly use your last name, email, or phone number. The Foundation for Peripheral Neuropathy has the right to edit or modify your submission without further approval from you. You release the Foundation of Peripheral Neuropathy and its employees, directors and agents from any direct, consequential or incidental damages or liabilities regarding use of the Submission and your name/location as designated herein. You confirm that you are 18 years or older.