| Are you looking for a
patient or a parent?* |
|
| Your Full Name* (middle name not necessary): |
|
Are you requesting a contact with a specific
form of EB? If yes, please state what form or forms of EB your
contact should have:* (Please be as specific as possible-for example,
don't just state 'dystrophic' since it varies so much, tell us if
it's the dominant form or the recessive etc, as another example,
with simplex, it's helpful to know if you're dealing with DM or
Koebner etc)
|
PLEASE
NOTE: THIS IS A FIELD THAT HELPS FILTER DOWN YOUR CHOICES, IT IS
RECOMMENDED THAT YOU PICK A FORM OF EB
P.S. If you don't
mind what form of EB the contact should have, please state 'ANY' on
this field. Thank You! |
| Should the patient be a certain age? If yes,
please state a range* (examples are: 'infant', toddler', 9-12
years old, pre-teen, teenager, adult 20+ or an exact age, such as 15
years old): |
PLEASE NOTE: THIS IS A FIELD THAT HELPS FILTER
DOWN YOUR CHOICES, IT IS RECOMMENDED THAT YOU PICK AN AGE
GROUP
|
| Should the patient be geographically near you?
If yes, please state a range* (examples are: same state/country, 2-3
states/countries away-but only if countries are small!-, same
continent, simply same language spoken): |
PLEASE NOTE: THIS IS A FIELD THAT HELPS FILTER
DOWN YOUR CHOICES, IT IS RECOMMENDED THAT YOU PICK A GEOGRAPHICAL
AREA
|
| Are you the parent of an EB angel seeking
support? * :
|
|
| Address*:(please include city, state and
zip): |
|
| Phone Number: (please include area code): |
|
| Email address*:(this is only required because I would like to
be able to contact you via email to give you the information you are
seeking! If this field is left blank, your request will be ignored.
THANK YOU!) |
|
