Share Your Story

First name*

Last name*

Email*

Address*

City State / Province / Region ZIP / Postal Code Country

Cell Phone

Please share your blood clot experience*

Did you have any risk factors that may have contributed to your blood clotting experience?*

e.g., estrogen-based birth control, long travel, surgery, hospitalization, etc.

What is your diagnosis?*

e.g., DVT, PE, factor v Leiden, etc.

Choose your age range when first diagnosed.*

Which race or ethnicity best describes you? Please check all that apply.*

Which gender best describes you?*

If you have factor V Leiden, which type do you have?

Homozygous
Heterozygous
I don't know

How has your experience with blood clot changed your life or lifestyle, if at all?*

What have you learned since this experience? Have any NBCA resources or services been helpful to you during your diagnosis or recovery?*

If you have a clotting disorder, have any of your family members been tested? If so, what have you learned from these test results?

What are your social media handles? (Instagram, Facebook, Twitter)

What advice would you like to give to others?*

Clotiversary Date (if applicable)

Upload a photo of you in .JPG or .PNG format*

Accepted file types: jpg, jpeg, png, gif, Max. file size: 64 MB.

Upload a photo of you in .JPG or .PNG format

Accepted file types: jpg, jpeg, png, gif, Max. file size: 64 MB.

Upload a photo of you in .JPG or .PNG format

Accepted file types: jpg, jpeg, png, gif, Max. file size: 64 MB.

Upload a photo of you in .JPG or .PNG format

Accepted file types: jpg, jpeg, png, gif, Max. file size: 64 MB.

Consent*

I have read and agreed to NBCA’s Release Form*

I understand that by submitting this form I agree to allow the National Blood Clot Alliance (NBCA) to use the information, photo and or video that I am voluntarily submitting as outlined in the Release Form.

Would like to receive communications from the National Blood Clot Alliance?*

Yes
No

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Patient Story Submission Form

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