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Share Your Story Form

You will be answering a series of questions to tell your story. All stories will be reviewed and if your story meets all of our guidelines, we will notify you before posting it on our web site.

Your confidentiality is a top priority. Please review our privacy statement before you continue.

For more information on how to tell a story, take a look at a sample story or check out our Story Guidelines and Frequently Asked Questions.
Please fill in the information below and click the submit button at the bottom of the page. Or you may handwrite your story and fax to 404.727.4583 or mail to Emory Department of Pediatrics, Office of Development, 2015 Uppergate Drive, Atlanta, Georgia, 30322

(* required field)
Author: *
Relationship to Patient:
Address: 
Phone: *
E-mail:
Patient Name: would like to remain anonymous:(check here)
Patient Age:
Patient Diagnosis:
Patient Physician:
Loc. of Treatment:
Synopsis of Story (2000 words max) *
Upload Photo:
(max size: 5mb)

  
   
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