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First Name
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Last Name
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Email
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Phone
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Relationship with porphyria
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I have porphyria
My child has porphyria
My partner has porphyria
Other
Diagnosis
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Acute intermittent porphyria (AIP)
Congenital Erythropoietic Porphyria (CEP)
Delta-aminolevulinic acid (ALA) dehydratase deficiency porphyria (ADP)
Erythropoietic Protoporphyria (EPP)
Hepatoerythropoietic porphyria (HEP)
Hereditary Coproporphyria (HCP)
Porphyria Cutanea Tarda (PCT)
Variegate Porphyria (VP)
X-Linked Protoporphyria
Undiagnosed
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Date of birth
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Gender
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Is there anything in particular that you'd like to discuss on your call?
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I understand that UPA will share my phone number and email address with the program Ambassadors so they can contact me.
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