AKU - LIVE Patient Registration Request Form

LIVE Patient Registration Request Form

Select one of the options:

Patient over 18 years

Enter data on behalf of an under 18 patient

IF the information is being added by the parent or guardian of a child with AKU, please enter the information as if the child is completing the form.

Form more information explaining how we use personal information we collect through this portal please see our Privacy Notice.

Title:

Patient First Name

Patient Last Name

Patient E-Mail

Patient Contact Number

Do you have a confirmed diagnosis of AKU?

Yes No

If confirmed, was a urine homogentisic acid test positive?

Yes No

Date of Diagnosis

Clinic/Hospital Name

Patient Date of Birth

Parent/Guardian Name

Parent/Guardian Surname

Parent/Guardian Email

Parent/Guardian Contact Number

I give my informed consent as outlined in the patient informed consent form (Patient Consent Form).

I have read the Terms and Conditions as per this link - (Privacy Notice)