Patient Contact Form - Chelsea's Hope Lafora Children Research Fund

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Patient Contact Form

Chelsea’s Hope would like to communicate with you to share announcements, research studies, trials, and therapy information. Your information will be kept private and only shared with your permission.

Step 1 of 4

25%

Name(Required)

First Last

Email(Required)

Relationship to Patient(Required)

Mother

Father

Sibiling

Other

Primary Language Spoken(Required)

Second Language Spoken

Number of living children diagnosed with Lafora Disease?(Required)

Number of deceased children diagnosed with Lafora Disease?(Required)

Patients / Childrens Information

First Patient's Name(Required)

First Last

Patient's Date of Birth(Required)

MM slash DD slash YYYY

Diagnosed by(Required)

Genetic Testing

Skin Biopsy

Known family member

Other

Patient's Gene Mutation(Required)

EMP2A

EMP2B (NHLRC1)

Other

Patient's Sex at Birth(Required)

Male

Female

Other

Age of first experience with tonic clonic (grand mal) seizure(Required)

Second Patient's Name(Required)

First Last

Patient's Date of Birth(Required)

MM slash DD slash YYYY

Diagnosed by(Required)

Genetic Testing

Skin Biopsy

Known family member

Other

Patient's Gene Mutation

EMP2A

EMP2B (NHLRC1)

Other

Patient's Sex at Birth(Required)

Male

Female

Other

Age of first experience with tonic clonic (grand mal) seizure(Required)

Patients' Address(Required)

City State / Province / Region ZIP / Postal Code Country

Copy of Genetic Tests

Max. file size: 50 MB.

Patient / Child Information

Patient's Name(Required)

First Last

Patient's Date of Birth(Required)

MM slash DD slash YYYY

Diagnosed by(Required)

Genetic Testing

Skin Biopsy

Known family member

Other

Patient's Gene Mutation

EMP2A

EMP2B (NHLRC1)

Other

Copy of Genetic Test

Max. file size: 50 MB.

Patient's Sex at Birth(Required)

Male

Female

Other

Patient's Address(Required)

City State / Province / Region ZIP / Postal Code Country

Age of first experience with tonic clonic (grand mal) seizure(Required)

Doctor's Name(Required)

First Last

Doctor's Email

Doctor's Hospitals(Required)

Please select what information you would like to be contacted about:

Clinical Trials

Family Support

Educational Events

Research Updates

Newsletter

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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

Chelsea’s Hope, Post Office Box 348626, Sacramento, CA 95834

info@chelseashope.org

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