Clinician Network Registry Referral Form

Use this form to recommend a provider you believe would be a valuable addition to the Chelsea's Hope Lafora Clinician Network Registry. This form may be submitted by patients, families, or fellow clinicians. Please submit one referral per form entry. We are building a Lafora Clinician Network Registry to serve as a trusted, centralized resource connecting patients and families to providers with experience or dedicated interest in Lafora disease. We believe that the people closest to the Lafora disease community—patients, families, and fellow clinicians—are best positioned to help us identify the providers who should be part of this network. Thank you for taking the time to submit a referral. Your recommendation helps us grow a community of knowledgeable, dedicated clinicians and ensures that no patient or family has to search alone for the care they need. We appreciate your help to expand access to quality care for Lafora patients. Any questions can be directed to info@chelseashope.org.