SSADH Association

SSADH Patient Registration

Contact Information

Country
Email*
Confirm Email*
Phone
Date of Birth
Primary Contact for Patient (First and Last Name)
Primary Contact Email Address
Secondary Contact for Patient (First and Last Name)
Secondary Email Address
What tests have you undergone?
Diagnosing Physician Type
Diagnosing Physician Name
Diagnosing Practice Specialty
Clinic Name where diagnosed
Clinic City where diagnosed
Clinic State/Province where diagnosed
Clinic Zip/Postal Code where diagnosed
Clinic Country where diagnosed
Genetic Trait
Mutation Type
Exon (Example: 1-9)
Nucleotide Change (Example: c.612G>A or c.34dupG)
Protein Change (Example: p.W204 or p.A12fsX123)
Exon #2
Nucleotide #2
Protein #2
Additional Comments

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