2026 New Patient Registration Form

TCSF SCN8A Families Support Group Intake Form
Applicant's Full Name

First NameLast Name
SCN8A Patient Full Name

First NameLast Name
SCN8A Patient Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient specific mutation on the SCN8A gene (sometimes called a "variant" on your report and starts with "p."). For example it might look like this: p.V1592L. NOTE: You may need to phone your neurologist for this information if the physician did not provide you with a report.
City of Residence
State/Province of Residence
Country of Residence
Address

CityState / Province

Postal / Zip CodeCountry
Primary E-mail
example@example.com
Secondary E-mail
example@example.com
Are you the legal parent/guardian and primary caregiver (legally responsible for medical decisions) for a patient with an SCN8A mutation?
Due to privacy, we limit membership in our support group to legal guardians and adult patients only.
Once added to the group, we like to write a brief introduction about the newest member so each family is aware and can welcome new parents. If you can please send just bit of his/her SCN8A journey for the introduction, that would be great!
Should be Empty:

TCSF SCN8A Families Support Group Intake Form