OGT Foundation New Patient

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Please complete and submit this form once for each family member that has been diagnosed with OGT.

I agree and acknowledge that I am authorized to provide the following information about myself, my family and the person(s) diagnosed with OGT listed hereafter.

Required

Your First Name *

Your Last Name *

Please select your Relationship to the individual diagnosed with OGT
*

Parent

Spouse

Caregiver

Self

Other:

Do you have more than one family member in your household diagnosed with OGT?
*

Please complete and submit this form once for each family member that has been diagnosed with OGT.

Yes

Please provide the First Name of the individual diagnosed with OGT
*

Please provide the Last Name of the individual diagnosed with OGT
*

Please provide the Date of Birth of the individual diagnosed with OGT
*

YYYY

Please provide the Gender of the individual diagnosed with OGT
*

Male

Female

Please provide the Race of the individual diagnosed with OGT
*

American Indian/Alaskan Native

Asian

Black or African American

Caucasian/White

Hispanic or Latino

Other:

Please enter the approximate year that the confirmed OGT diagnosis was made

Is the individual with OGT living?
*

Yes

Please provide the Name of the Primary Medical Center where you seek treatment for OGT related issues

This may or may not be geographically close to your home.

Please provide the Name of the OGT individual’s Primary Physician who provides OGT-related oversight and care

Please select the Type of Specialty of the Primary Physician, listed in the question above if answered, who provides OGT-related oversight and care

Genetics

Neurology

General Pediatrics (your Pediatrician)

Hematology

Endocrinology

Gastroenterology

Cardiology

General Internal Medicine

Other:

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Would you like to volunteer to become a Family Support Ambassador for OGT Foundation?

Family Support Ambassadors are experienced with OGT and are willing to reach out to newly diagnosed families, typically in his/her geographic region and/or his/her native language to provide support, and share experiences about resources and living with OGT

Yes

Clear selection

Email *

Phone

Start with a country code (e.g. +1, +34, +44)

Street Address 1 *

Street Address 2

City *

State/Province *

ZIP / Postal Code *

Country *

Contact Policy *

I understand and agree that OGT Foundation may contact me to inform me about OGT related events, education programs, resources and/or opportunities, advocacy efforts, research studies and clinical trials, offered by or in conjunction with OGT Foundation.

Thank you!

As a next step - join our Facebook community where we announce events, meet and support each other, and share our day to day life!

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