District 4 Medical Registration Form - Fall 2021
Free medical meetings are available on Saturday afternoon. This is your chance to talk to a knowledgeable dwarfism specialist about whatever concerns you may have. The consults will be around 15 - 20 minutes per session, but you may sign up for more than one doctor.

You will have a response to your registration request within 2 - 3 weeks via email. Your appointment time and details will not be finalized until you arrive at the regional at the registration desk. You must be registered for the Regional before being able to obtain an appointment.

Please note that medical professionals will not fill prescriptions during the Regional. Also, you will be required to sign a medical waiver before meeting with the physicians.
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First Name: *
Last Name: *
Street Address: *
City: *
State: *
Zip Code: *
Cell phone (the one with you at the regional): *
Email: *
Gender:
Parent/Guardian Names: (if member is a minor) *
Birthdate: *
MM
/
DD
/
YYYY
Diagnosis: If unknown, please bring x-rays and medical records for review. *
Age at Diagnosis:
How was your diagnosis made?
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Please list your questions or concerns for the physicians: *
What specialists are you requesting to see? Please check all that apply. (Please note we are still waiting on physician schedules and will update as soon as we have them). *
Required
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