• SLC6A1 Patient Database

    SLC6A1 Patient Database

    Please complete this form so we can continue our patient advocacy for our SLC6A1 community.

  • Family Contact Information

  • Relationship to patient
  •  -

  • Family History

  • Are either biological parents a carrier or mosaic carrier of the SLC6A1 mutation?*

  • SLC6A1 Child(s) Information

  • Patient 1 Date of Birth
     - -
  • Patient 1 Gender

  • Patient 1: Does your child have another gene mutation besides SLC6A1?
    If so, please list the name(s) here: .

  • Patient 2 Date of Birth
     - -
  • Patient 2 Gender

  • Patient 2: Does your child have another gene mutation besides SLC6A1?
    If so, please list the name(s) here: .

  • Patient 3 Date of Birth
     - -
  • Patient 3 Gender

  • Patient 3: Does your child have another gene mutation besides SLC6A1?
    If so, please list the name(s) here: .

  • Patient 4 Date of Birth
     - -
  • Patient 4 Gender

  • Patient 4: Does your child have another gene mutation besides SLC6A1?
    If so, please list the name(s) here: .

  • Research Registrations

  • Preferred language
  • Have you registered with Simon Searchlight?
  • Have you registered with Citizen Health?
  • Have you registered with Matrix?

  • Centers of Excellence

  • Has the patient been seen at one of our Centers of Excellence? (e.g. Colorado Children's Hospital, Children's Hospital of Philadelphia, UTSW)
  • If so, which ones:
  • Has the patient ever taken Ravicti?
  • Has the patient ever taken Butyrate (e.g. sodium butyrate, tributyrin, Sunbutyrate)?
  • Should be Empty: