FANCSA Professional Connections Form
Thank you for connecting with FANCSA! Whether you would like to collaborate, partner with us, continue a conversation, refer an FA patient or family to FANCSA, or simply stay connected, we’d love to connect!
Name & Surname
*
First Name
Last Name
Organisation / Institution
*
Profession / Role
*
Town / City
*
Email
*
example@example.com
Phone / WhatsApp Number
*
Please enter a valid phone number.
Format: (+27) 00 000 0000.
Website (Optional)
How can we connect?
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I would like to learn more about FANCSA
I would like to explore a partnership or collaboration
I would like to continue a conversation started at the conference
I work with / know an individual or family affected by Fanconi Anaemia
I would like to connect FANCSA with my organisation / network
I would like to stay connected for future opportunities
Other
Preferred Contact Method
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Email
Phone
Best Time to Contact
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Morning
Afternoon
Evening
Any additional message or comments you would like to provide
P.S. Doctors & allied healthcare professionals…
Have an FA patient or family who would love to meet Benji the African Honey Badger? We'd love to explore a special visit; whether at the hospital, clinic or another suitable setting. All visits would be arranged with the treating team and hospital's infection-control requirements in mind.
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