Your Stop the Clot® Stories

I want to share my #stoptheclotstory to help raise awareness about blood clots.

Patient Story Submission Form

First name*
Last name*
Email*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
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.
How has your experience with blood clot changed your life or lifestyle, if at all?*
What have you learned since this experience and 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 advice would you like to give to others?*
Clotiversary Date (if applicable)
MM slash DD slash YYYY
Upload a photo of you in .JPG or .PNG format*
Accepted file types: jpg, jpeg, png, gif, Max. file size: 64 MB.
Video story submission (optional)
Max. file size: 64 MB.
Please feel free to include a video of yourself telling your story as another way to share.
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

Privacy Statement: Your privacy matters to us. Unless compelled by law, the National Blood Clot Alliance (NBCA) will not sell, share, borrow or barter your private information with any third-party organization, company, or group. Your contact data is safe with NBCA.

Contact: Contact NBCA’s Communications Department for more information: info@stoptheclot.org

Share Your Stop the Clot® Story

Patient Story Submission Form

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