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Register as a Patient Family
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Patient Family
Please fill out the following information:
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Name(s) of Parent/Caregiver
*
Name(s) of Child(ren) Diagnosed with Cockayne Syndrome
*
Age(s) of Child(ren) Diagnosed with Cockayne Syndrome
*
Address
Email
*
Phone
Diagnosis/Mutation
Cockayne Syndrome (CSA/ERCC8)
Cockayne Syndrome (CSB/ERCC6)
Cockayne syndrome and Trichothiodystrophy (TTD)
Other (fill in below)
If Other, please fill in below:
Severity Level
Type 1 (Moderate)
Type 2 (Severe)
Type 3 (Mild)
Unknown
May we contact you by phone and/or email?
Yes
How many children are diagnosed with Cockayne Syndrome in your family?
How many children diagnosed with Cockayne syndrome are alive in your family?
What is your child or children's diagnosis date?
What are your social media handles? (Twitter, Instagram, Facebook, TikTok)
How can we support or assist you?
What is your primary language?
Submit
