PTENUKI BUDDY SCHEME
REGISTRATION FORM
Name: *
Address (including Post Code): *
Email address: *
Mobile phone:
Date of Birth: *
MM
/
DD
/
YYYY
Gender:
Clear selection
Name of Hospital(s) / regional centre:
Name of Genetic Consultant:
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
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.
Clear selection
Particular support you are looking for at this time?
Have specialist knowledge/ experience e.g. thyroidectomy/prosthetic surgery/genetic counselling
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