Potocki-Lupski Syndrome DATA BASE-Registry
Potocki-Lupski Syndrome Foundation, Inc Generated Data Base and Registry. Please use this registry and database to register individuals with Potocki-Lupski Syndrome (PTLS). The information and the data provided is HIPAA Privacy Laws protected. All information is to be used to generate a registry, as well as a database for research and education purposes.

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Email *
Child with PTLS- Last Name *
* required
Child with PTLS- First Name *
* required
Gender of child with PTLS *
* required
Parent or Guardian's Name (Last, First) *
* required
Address *
Put "none" if not comfortable with giving address
State / Province *
* required
Country *
* required
Postal Code *
* required
Email *
Phone Number (optional)
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This form was created inside of Potocki-Lupski Syndrome Outreach Foundation, Inc.