HDU Membership

First Name (required):

Last Name (required):

Your Email Address (required):

Address (required):

City (required):

State/Province (required):

Zip/Postal Code:

Country:

Phone (required):
()

About You:

Please tell us a little bit about yourself:

Your age (optional):

Gender (required):
MaleFemale

Are you (please select one):

If you are on dialysis, what year did you start?:

If you are currently on dialysis, what type of dialysis are you on now?:
Home hemodialysisPeritoneal DIalysisIn-center hemodialysis

If you are dialyzing at home:

When did you begin home dialysis?:

Which home dialysis machine?:
NxStage System OneFresenius 2008CAPDBaxter HomeChoiceFresenius LibertyOther

How did you hear about the HDU?:

Any comments or special requests: