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PKD Australia Register
We are working towards building a community of people interested in PKD, if you’d like to be part of this please complete the following information.
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First Name
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Your answer
Surname
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Your answer
What is your gender?
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Choose
Male
Female
Address
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Your answer
Suburb
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Your answer
State
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Choose
Australian Capital Territory
New South Wales
Northern Territory
Queensland
South Australia
Tasmania
Victoria
Western Australia
Post Code
*
Your answer
Country
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Your answer
Email Address
*
Your answer
Phone Number
Your answer
What is your connection to PKD?
*
I have ADPKD
I have ARPKD
A family member has PKD
A friend has PKD
Other:
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My Medical Specialist is...
Your answer
Are you interested in helping or fundraising for PKD Foundation?
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No
Not right now
If you have any other comments, please place them here
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I am happy to receive information from PKD Foundation of Australia
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