New Patient Registration Form

SCN8A Family Contact Information:
Applicant's Full Name*

First NameLast Name
SCN8A Patient Full Name*

First NameLast Name
SCN8A Patient Date of Birth

MonthDayYear
Date
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.*
Address*

CityState / Province

Postal / Zip CodeCountry
E-mail*
example@example.com
E-mail
example@example.com
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:

SCN8A Family Contact Information: