We want to find all U.S. survivors of the drug thalidomide for our future advocacy efforts.
If you believe you are a survivor of thalidomide, and were born in the United States between December, 1956 and December, 1967, please fill out the form below in its entirety. Also please upload a photo of yourself that shows your disability, and send to the USTS Communications Director at email@example.com, with your name noted in the subject line.
Please note that incomplete forms may not be processed. If you need assistance, please email firstname.lastname@example.org.
Can’t see the form below? Click here.