District 4 Medical Registration Form
Free medical meetings are available on Saturday afternoon. This is your chance to talk to a knowledgeable dwarfism specialist about whatever concerns you may have. The consults will be around 15 - 20 minutes per session, but you may sign up for more than one doctor.

You will have a response to your registration request within 2 - 3 weeks via email. Your appointment time and details will not be finalized until you arrive at the regional at the registration desk. You must be registered for the Regional before being able to obtain an appointment.

Please note that medical professionals will not fill prescriptions during the Regional. Also, you will be required to sign a medical waiver before meeting with the physicians.

First Name *
Your answer
Last Name *
Your answer
Street Address: *
Your answer
City: *
Your answer
State: *
Your answer
Zip Code: *
Your answer
Cell Phone : *
(the one with you at the regional):
Your answer
Email: *
Your answer
Gender: *
Your answer
Parent/Guardian Names: *
(if member is a minor):
Your answer
Birthdate: *
MM
/
DD
/
YYYY
Diagnosis: *
If unknown, please bring x-rays and medical records for review.
Your answer
Age at Diagnosis:
Your answer
How was your diagnosis made?
Please list your questions or concerns for the physicians: *
Your answer
What physicians are you requesting to see? Please check all that apply. *
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