Potocki-Lupski Syndrome DATA BASE-Registry
Potocki-Lupski Syndrome Foundation, Inc Generated Data Base and Registry
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.
Child with PTLS- Last Name *
* required
Your answer
Child with PTLS- First Name *
* required
Your answer
Gender of child with PTLS *
* required
Parent or Guardian's Name (Last, First) *
* required
Your answer
Address *
Put "none" if not comfortable with giving address
Your answer
State / Province *
* required
Your answer
Country *
* required
Your answer
Postal Code *
* required
Your answer
Email *
Your answer
Phone Number (optional)
Your answer
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