Cure Story Submission Form


Please fill in the following information in order to contribute your story to www.impossiblecure.com.

All stories will be screened before they are posted to the website to safeguard against offensive or defamatory content. It will not be screened for accuracy. Screening usually takes from one day to one week. Please be aware that your story will not be edited -- so be sure to proofread your submission carefully before you finalize it.

Your submission of this form is taken as legal permission to share this information globally on the World Wide Web. Furthermore, submission of this form indicates your acceptance of these terms.

Required fields are preceded by a "*".

STEP ONE. PUBLIC INFORMATION

Your Contributor Name, Contributor City, and Primary Complaint will be made public on the web site along with your story. If you wish your contribution to be anonymous, fill in "Anonymous" as your Contributor Name. However, your contribution will be more valuable and credible if you supply your name. We do ask that you fill in your city. If you also wish to make your email public, fill it in as "Contributor Email."

*Contributor Name:
*Contributor City:
*Primary Complaint or Illness:
Contributor Email:

STEP TWO. PRIVATE INFORMATION

Please supply the contact information below. It will be kept in our private data base and will not be shared with any other organization.

*Email:
*Name:
*Street Address:
*City:
*State/Province:
*Postal Code:
*Country:
Phone number:

Would you consider allowing the use of your story in published form (in a possible follow-on book to Impossible Cure)? Yes No

STEP THREE: YOUR STORY (This is PUBLIC information):



STEP FOUR: