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Have you been diagnosed with NSF (Nephrogenic Systemic Fibrosis) or NFD (Nephrogenic Fibrosing Dermopathy)? Yes No
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When did your problems start?

Describe your symptoms and how they developed.
Did you have an MRI (Magnetic Resonance Imaging) or MRA (Magnetic Resonance Angiography) scan done before your symptoms began? Yes No
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Did you have kidney failure, kidney function deficiency, or other kidney problems at the time the scan (or scans) were done? Yes No
Describe the kidney problems you had.

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PERSONAL INFORMATION
First Name: *
Last Name: *
Address:
City:
State:
Zipcode:
Phone: -- ext.
Work Phone: -- ext.
E-mail Address: *
CASE INFORMATION
Have you been diagnosed with NSF (Nephrogenic Systemic Fibrosis) or NFD (Nephrogenic Fibrosing Dermopathy)? Yes No
When and where was the diagnosis made?
When did your problems start?

Describe your symptoms and how they developed.
Did you have an MRI (Magnetic Resonance Imaging) or MRA (Magnetic Resonance Angiography) scan done before your symptoms began? Yes No
Where and when was the scan (or scans, if more than one) done?
Did you have kidney failure, kidney function deficiency, or other kidney problems at the time the scan (or scans) were done? Yes No
Describe the kidney problems you had.
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