CMN Africa 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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/
DD
/
YYYY
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)?
Clear selection
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: *
E-Mail Address: *
Other comments:
Do you agree to have your pictures/ CMN stories published on social media/ our website/ printed information/marketing materials? *
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