AHC Registration Form


You are asked to enroll in the AHC Registry so that we may quickly and efficiently contact you in the future with information about new treatments for AHC, or about studies for which you may be eligible. Additionally, we are asking you to enroll so that we have a better understanding of how many people are affected with AHC. The primary benefit to you is that you will be contacted as soon as we launch any AHC research study in which you may be eligible to participate, or as soon as we find a new treatment for AHC. The secondary benefit is that you will know that you are accounted for in AHC Registry, which is our way of counting how many people have AHC. Knowing how many people have the disease is an important piece of information for obtaining funding of studies on AHC. Risks include the very small risk of loss of confidentiality that results from any activity involved in disclosing personal information.



Today's date : / /

     Name of person completing this form :

First :     Last :

Relationship to patient :         



Patient Information

     Patient's Name :

First :     Last :

Patient's date of birth : / /

Gender :        Race :

Patient's address :
Street :
City :     State :     Postal Code :
Country :
Patient's home phone :
Patient's cell phone :
Patient's primary email :
Patient's secondary email :



Mother's Information

     Mother's Name :

First :     Maiden :

Mother's date of birth : / /

Mother's address :
Street :
City :     State :     Postal Code :
Country :
Mother's home phone :
Mother's cell phone :
Mother's work phone :
Mother's primary email :
Mother's secondary email :



Father's Information

     Father's Name :

First :     Last :

Father's date of birth : / /

Father's address :
Street :
City :     State :     Postal Code :
Country :
Father's home phone :
Father's cell phone :
Father's work phone :
Father's primary email :
Father's secondary email :



Legal Guardian's Information (If other than parent or patient)

     Legal Guardian's Name :

First :     Last :

Legal Guardian's date of birth : / /

Legal Guardian's address :
Street :
City :     State :     Postal Code :
Country :
Guardian's home phone :
Guardian's cell phone :
Guardian's work phone :
Guardian's primary email :
Guardian's secondary email :



Doctor's Information

     Doctor's Name :

First :     Last :

Doctor's specialty :          Doctor's phone :

Doctor's address :
Street :
City :     State :     Postal Code :
Country :



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