Registration

Welcome! Please provide the following information to register as a member of the NFDF. Your personal information will not be shared according to the NFDF's privacy policy. Upon your first log-in after registration, you will have access to all web pages available to registered members. Visitors not registered with the NFDF will not be able to access some pages of the website or participate in some programs sponsored by the NFDF.

The information collected here is for the purpose of learning about and sharing accurate information with the Fabry disease community. Personal identification information will not be shared. The questions about physicians and genetic counselors are asked to help others locate healthcare professionals knowledgeable of Fabry disease.

* indicates required field
*USER_USERNAME**
*USER_PASSWORD**
*USER_CONFIRM_PASSWORD**
*USER_EMAIL**
  Prefix First* MI Last* Suffix
Name*

 

Your Information

Nickname

Gender*

Male   Female 

Address*



City/State/Zip*

City*

ST*

Zip*

Location

County

Country

Phone

Birth date

e.g. 03051971

 


Institution or Business contact information
Institution or Company Name
Department
Your Title
Institution or
Company Address

City/State/Zip

City

ST

Zip

Country

Work Phone

Website

Office Contact


Fabry Information
*Do you have Fabry disease symptoms or carry the Fabry Disease gene? Yes/No
How many minor (under 18 years old) children do you have with Fabry Disease symptoms or that carry the Fabry disease gene?
Are you a healthcare provider involved with the management or care of individuals with Fabry disease?
If you are being monitored or treated for Fabry disease symptoms, who is the physician that is most involved in your management/monitoring? Doctor:  
Facility:
City: State:

Are you receiving Enzyme Replacement Therapy (ERT) to treat your disease symptoms?

Are you in contact with a genetic counselor regarding your Fabry disease management or monitoring?
If Yes, please provide:

 Name:  
Facility:
City: State:

Are you interested in becoming more active in support of the Fabry disease community?


Comments

Please include any other comments you may have that could be helpful.

 




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