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Canine Registry
Add your dog to the Lafora Disease Canine Registry. If you have any questions, please email katherine@chelseashope.org.
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Email
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Your email
Full Name:
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Your answer
Contact Phone Number:
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Your answer
Country:
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Your answer
Dog's Name (if multiple dogs, separate each name by a comma):
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Your answer
Breed:
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Your answer
Age:
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Your answer
Gender:
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Your answer
Date of Diagnosis (if unknown, write n/a):
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Your answer
Symptoms Observed (check all that apply):
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Hypnic jerks
Spontaneous and reflex myoclonus
Vision loss
Ataxia
Decreased cognitive function
Other:
Required
Date of Onset of Symptoms (month/year; if unknown, write n/a):
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Your answer
Genetic Testing Results (mutation present, if known, write 'n/a' if unknown):
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Your answer
Current Medications or Treatments:
Your answer
Veterinarian's Name:
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Your answer
Veterinarian Clinic/Hospital
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Your answer
Veterinary Contact Phone Number:
Your answer
Veterinary Contact Email:
Your answer
Is the dog participating in any research studies related to Lafora disease?
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Yes
No
If yes, what is the name of the study/trial?
Your answer
Would you like to be notified of any research studies related to Lafora disease?
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Yes
No
Would you like to be added to the Chelsea's Hope Newsletter?
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Yes
No
Additional Information:
Your answer
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