PATIENT registration form - Cutis Laxa Days Ghent

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PATIENT registration form - Cutis Laxa Days Ghent

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* Indicates required question

Patients name *

Your answer

I (We) will be attending the 6th CL Days in Ghent

Choose

1 person (patient)

2 (patient + 1 relative)

3 (patient + 2 relatives)

4 (patient + 3 relatives)

5 (patient + 4 relatives)

Children attending under 12y

Choose

0

1

2

3

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