DEMO 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.
For more information explaining how we use the personal information we collect through this portal please see our
Privacy Notice
Title:
Mr
Mrs
Miss
Ms
Prof
Dr
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
Please confirm your urine homogentisic acid (HGA) test result either at diagnosis or since then:
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
)
Send