1 on 1 Consultations

2014-Neutropenia-Family-conf-web-253One-on-One Consultations with the Experts

When you register for the 2015 Neutropenia Family Conference you are eligible so sign up for one of our most popular Conference features, a one-on-one consultation with an expert physician/member of the Severe Chronic Neutropenia Advisory Board. We  make every effort to accommodate all requests though we cannot guarantee it.  You must register for the conference to be considered for a private consultation.

Please complete the form below if you wish to have a physician consultation.  We will get back with you within two weeks after you apply to let you know your request has been accepted, but we cannot give you the exact time of your consultation or the name of the physician you will be meeting with until late June. Please feel free to email us with any questions.


Your Name*

Patient's Name*

Your Email*

Mailing Address*



Zip Code*

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:

Please type the caracters of this captcha so we know your real: