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 on behalf of a patient, please enter the information as if the patient is completing the form.
For more information explaining how we use personal information we collect through this portal please see our
Privacy Notice
Enter data on behalf of an AKU patient
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
Patient Date of Birth
Guardian Name
Guardian Surname
Guardian Email
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
)
Send