| Are you a patient or a
parent?* |
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| Your Full Name* (middle name not necessary): |
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| Form of EB* (Please be as specific as possible-for example,
don't just state 'dystrophic', 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) |
P.S. If you are awaiting the results of a
biopsy, it's best to wait for the results before filling out this
form with 'unknown' form of EB - EB varies so much within the forms,
that it may actually be harmful to take advice from someone that
perhaps may be dealing with a different form of EB. If you're an
adult and you don't know, then please take a guess! Thank
You. |
| Year of birth of Patient* (full date of birth not
necessary-we just want to know the age basically, but DO NOT give us
the age because ages CHANGE, while the year of birth doesn't! THANK
YOU!): |
|
| Are you the parent of an EB angel available to
give support? * :
|
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| Address*:(please include city, state and
zip): |
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| Phone Number: (please include area code): |
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| Email address*: (this is only required because I would like
to be able to contact you to let you know someone would like to
contact you for support-if you do not have an email address, I will
not notify you and I will let the person seeking contact snail mail
or phone you): |
|
