If you would like to nominate someone for a monthly spotlight patient please read the requirements and fill out this form!

Requirements-

ONE of these:
-Someone who needs help as soon as possible for gastroparesis
-Someone who has recovered from gastroparesis or has improved. Please state reason (if known)
-Someone who is achieving a lot in spite of gastroparesis

Additional Requirements:

-Must have been diagnosed with gastroparesis as described on the gastric emptying test results or other reliable testing
-Willingness to send a photo to be displayed on the website and quarterly newsletter
-Willingness to share experiences through G-PACT's publications (website, newsletter).

Note- G-PACT will NOT use any personal or medical information you provide without your permission. All information we receive will remain confidential and only be used once we have selected you as our spotlight. We will seek your approval and verification of accuracy of all information before publication. Please click here for our privacy statement.
 

Information on Spotlight Nominee (US Citizens Only):

Title*
First Name*
Last Name*
Street Address
Street Address Line Two (optional)
City
State
Zip
Phone
E-mail*
Type of GP (diabetic, post-surgical, idiopathic, etc)

Reason for Recommendation*:

Person Recommending (Title)* 
First Name*

Last Name*

Street Address*

Street Address Line Two (optional) 
City*
State*
Zip*
Phone
E-Mail*
Relationship to Nominee*

 

 


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