PATIENT REGISTRATION SYSTEM

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PATIENT REGISTRATION FORM

Name *

Surname *

Date of Birth *

City of Residence *

County of Residence *

Phone Number *

E-mail Address

Age at Which You are Diagnosed with Cystinosis *

Hospital Where You Continue Treatment *

Hospital Where You Continue Doctor *

Treatment Status *

Medication

Dialysis Treatment

Transplanted

Your Expectations from the Association of Cystinosis Patients *

YOUR PERSONAL INFORMATION YOU PROVIDED TO THE PATIENT REGISTRATION SYSTEM COMMITMENTS WILL NOT BE SHARED WITH A THIRD PARTY OR INSTITUTION IN ACCORDANCE WITH THE LAW OF PERSONAL INFORMATION PROTECTION.

I have read and approved the KVKK and Ligting Text.