1 on 1 Consultations

One-on-One Consultations with the Experts

Limited individual, one-on-one sessions with the expert physicians on hand at the 2012 Neutropenia Family Conference will again be available. Unfortunately not every request can be filled. To be considered, we need the following information to give to the physicians and for selection review. Selection criteria will hinge on a first come/first serve basis as well as the severity of the need for the consultation, and as deemed by the experts. You must register for the conference to be considered for a one-on-one session.

One-on-One Consultation Registration Form

Please submit this form as soon as possible. It is best to submit with your registration form, if possible. You will be notified if more information is necessary. Please feel free to email us with any questions. Every effort will be made to accommodate as many requests as possible.

Subject

Your Name (required)

Patient's Name (required)

Your Email (required)

Relationship to Patient

Current Age of SCN Patient

Age at Onset of Symptoms

Type of SCN

Have you ever met with any of the attending experts in the past?
 Yes No

If yes, when? (date)

Is the patient currently seeing a hematologist?
 Yes No

If yes, hemotologist's name, city and state?

Any current treatments ? (i.e. Neupogen, etc, please include dose)

Main concern(s) you would like to discuss?

Please include any other information you deem of importance:

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