Nevus Association South Africa Database
Database
First Name of Patient: *
Surname of Patient: *
Gender: *
Names of Parents (in case of minor): *
Profession/ Profession of Parents:
Date of Birth: *
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Place of Birth & Nationality:
Does the patient have any siblings?
Location of CMN: *
Required
Has the CMN been treated? *
If the CMN has been treated, please elaborate:
Has the patient had an MRI pertaining to the CMN? *
What were the findings of that MRI?
Has the patient been diagnosed with Neurocutaneous Melanocytosis (NCM)?
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Attending GP/ Paediatrician (with contact details): *
Attending Dermatologist (with contact details): *
Attending Neurologist (with contact details): *
Attending Surgeon (with contact details): *
Other Doctors (with contact details): *
Home Address: *
Mobile Number: *
Would you like to join our WhatsApp Group? *
E-Mail Address: *
Would you like to join our Facebook Group https://www.facebook.com/groups/256812154425109/
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What skills do you have to help our organisation grow?
Other comments:
Do you agree to have your pictures/ CMN stories published on social media/ our website/ printed information/marketing materials? *
How did you hear about us? *
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