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Clinician Application Form - Lafora Clinician Network Registry

We appreciate your interest in joining our Clinician Network. The goal of this registry is to identify clinicians who are committed to advancing the diagnosis, treatment, and holistic management of Lafora disease through coordinated care, patient advocacy, and collaborative expertise. The Lafora Disease Clinician Network will serve as a trusted, centralized resource connecting patients and families to providers with experience or dedicated interest in Lafora disease, ensuring access to knowledgeable, high-quality care. We are confident that this program will expand our ability to best support individuals affected by Lafora disease. Any questions can be directed to info@chelseashope.org. On behalf of the Lafora disease community, thank you for your commitment to advancing care for Lafora patients.

This field is for validation purposes and should be left unchanged.

General Information

Your Name(Required)
Clinical Specialty(Required)
Please indicate all specialties you provide.
Please share your other specialties.
Clinical Services(Required)
Please indicate all clinical services you provide.
Hospital/Clinical Affiliations Address(Required)
Email Address(Required)
Please briefly describe your experience with Lafora disease (3 to 5 sentences), or provide a link to your clinical bio if it includes relevant details.

Contact Information Privacy

We will respect your privacy and will only publicly share what you authorize us to.
What information can we display publicly?(Required)
Please indicate which of the following information you authorize Chelsea's Hope to display publicly on our website and clinician registry.
How would you prefer patients and families to reach you?(Required)
Please select your preferred contact method(s).
Please share your preferred contact method.

Languages and Location

Please list all languages in which you are comfortable providing clinical guidance or patient communication.
If yes, are there any geographic limitations or preferences?
If yes, please indicate which services are available via telemedicine and any limitations that apply (e.g., state/country restrictions, visit types).

Concluding Questions

Please indicate which of the following you would like to participate in:
Please use this space to list any additional information you would like to highlight in your clinical profile on our website.

Refer a Clinician

Do you know any other clinicians who would be a good fit for the Lafora Disease Clinician Network?

 

The mission of Chelsea’s Hope is to improve the lives of those affected by Lafora disease and help accelerate the development of treatments.

Chelsea’s Hope Lafora Children Research Fund is an IRS 501(c)3 non-profit organization. EIN: 27-1008382

Location imageChelsea’s Hope c/o Dr. Donohue

976 Maywick Dr.

Lexington, KY 40504

info@chelseashope.org

Use ICD-10 code G40.C for Lafora.

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