Join NATX Online

To become a NATX Member ($30), Partner ($50-99), or Ambassador ($100+) online, please complete these three easy steps:

1. Complete and submit this questionnaire;
2. Select a membership level that fits you;
3. Enter your payment information and check out.

New Member Information

If you are human, leave this field blank.

Order ID

Time

Date

ABOUT YOU

First Name *

Last Name *

Address1 *

Address2

City *

State *

ZIP *

Phone *

Email Address *

Preferred Contact Method * Make a Selection Phone Email Mail

What year are you paying for? * Make a Selection This Year Next Year

Your Relationship to Neuropathy * Make a Selection Patient Caregiver Other Your Relationship to Neuropathy

Primary Support Group Affiliation * Make a Selection Austin - Westlake Hills Austin - Northwest Hills Georgetown Houston None

Would you like to add another person to your membership? * Make a Selection Yes No

ADD ANOTHER PERSON

Their Name

Their Role Make a Selection Patient Caregiver Other Their Role

Their Email

PATIENT DEMOGRAPHICS

Date of Birth *

Gender * Make a Selection Female Male

Approximate Date of Symptoms Onset *

Approximate Date of Diagnosis *

Type of Neuropathy * Make a Selection Auto-immune, inflammatory (CIDP) Diabetic Idiopathic Hereditary (CMT) Cancer related Chemotherapy induced Drug/toxin induced Other Type of Neuropathy

Note:

Use this space for anything additional that you think is important for us to know.

Gifts to Neuropathy Alliance of Texas, a 501(c)(3) organization,
are fully tax deductible as allowed by law.
No fair market benefits are received.