PC Patient Support Meeting Registration

2014 Edinburgh Scotland Pachyonychia Congenita Patient Support Meeting

October 26-28, 2014. This meeting is co-sponsored by PC UK and PC Project and will be in English. The site will be the Best Western Edinburgh Capital Hotel in Edinburgh. The meeting will begin Sunday evening, October 26 with registration and a welcome dinner. The main presentations and discussions will be Monday, October 27 followed by a dinner that evening. The meeting will conclude after a noon luncheon on Tuesday, October 30.

For information on meeting fees and scholarships, please visit http://www.pachyonychia.org/news_events.php.

1. Please enter your contact information:

First Name

Last Name

Street Address

Apt/Suite/Office

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

Mobile Phone

2. Please tell us a little about yourself.

Age (if under 18)
Do you have PC?
Special dietary or other needs?

3. Have you submitted the IPCRR Consent Form, Questionnaire and photos to PC Project and completed the telephone consultation with the physician for the IPCRR?

4. With this be the first time you have attended a PC Patient Support Meeting?

Please enter an 'other' value for this selection.

5. Why would you like to attend this patient support meeting?

6. Please list any questions you would like discussed at the patient support meeting.

7. Family Member 1. Please provide information for those who will attend the meeting with you.

Name
Relationship
Age (if under 18)
Do they have PC?
Special dietary or other needs

8. Family Member 2. Please provide information for those who will attend the meeting with you.

Name
Relationship
Age (if under 18)
Do they have PC?
Special dietary or other needs

9. Family Member 3. Please provide information for those who will attend the meeting with you.

Name
Relationship
Age (if under 18)
Do they have PC?
Special dietary or other needs

10. Family Member 4. Please provide information for those who will attend the meeting with you.

Name
Relationship
Age (if under 18)
Do they have PC?
Special dietary or other needs

11. Additional Comments

PC Patient Support Meeting Registration - Scotland