PARENTS OF CAH CHILDREN

JOIN OUR COMMUNITY

Join here if you are a PARENT (only) of CAH CHILDREN. If you are also a patient, please use the Patient form by returning to our Join Our Community page on our website.

Please complete all fields and give us accurate information about your children. If you have more than three children with CAH, please use the notes section to give us that additional information. The more information we have, the better we can help you!

First Name *

Last Name *

P7: I am the parent of a child (or children) with CAH *

Yes

No

Address 1 *

Address 2

City *

State/Province *

Country *

Zip Code/Postal Code *

MOBILE PHONE NUMBER (if you do not have one, enter N/A and add a house or work phone below): *

Phone

Email *

Are you married? *

If married, please give your spouse's name *

What is the CAH status of your spouse? *

Please complete the following information about your children. Enter CAH affected child/children first. Please give complete birthday 00/00/0000. Please mark or write in "N/A" if doesn't apply.

C1a: CHILD 1 NAME *

C1b: CAH TYPE *

C1c: Birthday __/__/____ *

C1d: GENDER *

C1: YEAR BORN *

C2a: CHILD 2 NAME *

C2b: CAH TYPE *

C2c: BIRTHDAY __/__/____ *

C2d: GENDER *

C2: YEAR BORN *

C3a: CHILD NAME *

C3b: CAH TYPE *

C3c: BIRTHDAY __/__/____ *

C3d: GENDER *

C3: YEAR BORN *

C4: Hospital, clinic or practice where your child/children receive/s care. *

C5: Child's/Children's Doctor/s *

R1: Are you the relative (other than parent) or friend of a CAH-affected individual? *

Please list the names, CAH status, and date of birth of any other person/s in your household (other than spouse or children) *

Your message

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