PTENUKI BUDDY SCHEME
REGISTRATION FORM
Name: *
Your answer
Address (including Post Code): *
Your answer
Email address: *
Your answer
Mobile phone:
Your answer
Date of Birth: *
MM
/
DD
/
YYYY
Gender:
Name of Hospital(s) / regional centre:
Your answer
Name of Genetic Consultant:
Your answer
PTEN diagnosis (tick as many boxes that apply):
If you are answering for a Family member or Friend please put their name and age here
Your answer
ABOUT YOU/YOUR FAMILY:
We want to try and match our buddies to their needs. For example, somebody new to diagnosis may wish to chat somebody who has lived for sometime with theirs. Perhaps you might wish to chat with somebody of a similar age, or have specialist experience that you feel might be of use to somebody. You may have a young child, and would like information from families with older children / young people who can add insight to your children.
Particular support you are looking for at this time?
Your answer
Have specialist knowledge/ experience e.g. thyroidectomy/prosthetic surgery/genetic counselling
Your answer
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