2019 San Francisco Medical Consultation Form
Si necesita este formulario en espanol, por favor contacte a Colleen Gioffreda (cgioffreda@jhu.edu)

To register, you must return the MEDICAL CONSULTATION FORM in ONE of the following ways.
1. Fill out this medical form on the google forms doc.
2. Email the attachment to Colleen Gioffreda – at cgioffreda@jhu.edu
3. Fax to: (410) 502-2375.
4. Mail to:
Colleen Gioffreda
Johns Hopkins University
600 N. Wolfe Street
Blalock 1008
Baltimore, MD 21287

• Scheduling begins May 1, 2019. No appointments will be scheduled before May 1, 2019. (Feel free to send the form in beforehand, but the doctors’ schedules will not be confirmed until after that date).

• Appointments with specific physicians are made on a first-come, first-served basis. Due to the tight schedule of the doctors, you will be unable to see two doctors of the same specialty. (Only 1 appointment per specialty).

• We will confirm your appointment before the conference, but please keep in mind that doctors’ schedules are not always firm. Appointment letters will go out 2 – 3 weeks after receiving requests unless there is a scheduling question. (AFTER May 1st).
• You must return a completed MEDICAL CONSULTATION FORM before you will be scheduled in San Francisco.
• Unless otherwise noted on your medical consultation form, your confirmation letter with your appointment date and time will be emailed to you.
Free medical consultations with members of the Medical Advisory Board will be available Monday, July 1st , Tuesday, July 2nd , and Wednesday, July 3rd .

If you are a first-time consultation attendee or have general questions, we recommend an appointment with a geneticist who acts as a primary care provider for individuals with skeletal dysplasias.
Please be as specific as possible when listing your questions for physicians. If you have questions, please contact Colleen Gioffreda at cgioffreda@jhu.edu or (410) 614-0977.

You must be already registered for the LPA conference in order to be obtain an appointment with a provider.
• Please note: Medical professionals WILL NOT fill prescriptions during the Conference. Please make sure you bring appropriate medications in sufficient supply for the duration of the Conference.
• There will be no dentist appointments available. Also, Dr. Bober is not attending this year.

Email address *
First Name: *
Your answer
Last Name: *
Your answer
Gender: *
Your answer
Birthdate: *
Parent/Guardian names *
(If member is a minor)
Your answer
Address: *
Your answer
City: *
Your answer
State: *
Your answer
Zip code: *
Your answer
Home Phone:
Your answer
Cell Phone: *
Your answer
Diagnosis: *
If unknown, please bring x-rays and any medical records for review.
Your answer
Age at Diagnosis: *
Your answer
Who made your Diagnosis? *
Your answer
How was your diagnosis made? *
Please list your questions or concerns for the physicians: *
Your answer
What type of provider(s) are you requesting to see? Please check all that apply. *
*Some specialities may not be represented at this conference - we will let you know in your letter if the specialty is not available.
If you request a specific provider, please list him or her by name:
Appointments are made on a first -come, first-served basis.
Your answer
Clinic is on Monday, July 10th, Tuesday, July 11th, and Wednesday morning, July 12th. Please check the days and times that you are AVAILABLE. *
Please note any other comments on this form that you may want the provider(s) to know about you.
Your answer
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