Contact Registry Form - KCNQ2 Cure Alliance

I agree and acknowledge that I am authorized to provide the following information about myself, my family, and the person(s) with KCNQ2 listed hereafter. I also understand and agree that the KCNQ2 Cure Alliance may contact me about the activities of the Alliance, provide information to me about KCNQ2 and future research studies and trials.
Agreement*
- I Agree
- I Do Not Agree
Please carefully read the statement above. You must agree to the statement to be able to proceed with completing the contact registry.

Name*
First Last
Email*
Location*
Street Address City State / Province / Region ZIP / Postal Code Country
Gender*
- Male
- Female
- Other
I would like to add a spouse/partner to the contact registry*
- Yes
- No
Spouse/Partner Name*
First Last
Email*
Location*
State / Province / Region Country
Gender
- Male
- Female
- Other

Individual with KCNQ2 variant
Person's Name*
First name of person with KCNQ2
Gender*
- Male
- Female
Genotype*
Year of diagnosis*
Date of Birth*
MM slash DD slash YYYY

This information is only used to calculate the person's age when sending out information in regards to research for a specific age group.
Add new person with KCNQ2 variant*
- Yes
- No
Person's Name*
First name of person with KCNQ2
Gender*
- Male
- Female
Genotype*
Year of diagnosis*
Date of Birth*
MM slash DD slash YYYY

This information is only used to calculate the person's age when sending out information in regards to research for a specific age group.

Subscribe