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First Name

Last Name

Saluatation

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Address Line 1

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City

State/Province

Zip/Postal Code

Country

Phone Number

Specialty

Hospital Affiliation

Do you currently treat any chILD patients?

How Many?

Are you located at a chILD center?

Would you be interested in relocating to one?

Can we give your contact information to local families looking for a physician?

How would you like to be contacted?

Are you currently using the patient registry to track your chILD patients?

Would you like us to contact you about access to the registry?

Are you currently performing any chILD research?

What area of research are you in? What is your research topic?

Do you have any colleagues that should be added to our database?

Name, Specialty, E-Mail Address:		Order
		Weight for row 1

Would you like to be added to our physician List-serv and receive our family e-newsletter and announcements from the chILD cente

Child's First Name

Child's Last Name

Child's Date of Birth

Month

Day

Year

Date of Diagnosis

Month

Day

Year

Primary chILD Diagnosis

Other Diagnosis (if any)

Any Siblings Affected?

Name, Date of Birth, Diagnosis:		Order
		Weight for row 1

Primary Pulmonologist's Name

Primary Pulmonologist's Hospital

Other Pulmonologist's Name

Other Pulmonologist's Hospital

Pediatrician's Name

Contact by liaison?

Receive e-mails and e-newsletters from chILD Foundation?

Would you like to receive information on the patient registry?

Are you interested in copies of the child education materials?

Would you like to receive notification of upcoming research on any form of chILD?

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