The Lymphatic Research Foundation

LRF's NATIONAL LYMPHATIC DISEASE AND LYMPHEDEMA PATIENT REGISTRY

Do you suffer from lymphedema or a lymphatic disorder? Have you joined our patient registry?

Millions struggle with the pain, fear, disfigurement, medical complications and isolation caused by lymphedema and other lymphatic diseases. Your involvement can be the key to improved treatments and a cure. Patient information is a valuable resource for researching lymphatic diseases as well as recruiting participants for clinical trials. Only scientific research can discover improved treatments and a cure. Research is hope in action.

The identifying information provided below is confidential and will not be released without written consent. Since LRF's National Lymphatic Disease and Lymphedema Patient Registry is under development, the following data is being collected so that we can contact you to gather more extensive clinical information if you decide to participate in the program. You have the right to withdraw at any time.

This initiative is a major contribution to the scientific and medical communities who dedicate their life's work creating possibilities that do not yet exist. Please, share the dream and help us to help you. Take a moment to complete the form below.

If the patient is a child, please provide the Parent and/or Guardian's name in the space provided.

Also, please be sure to include any country and area codes in all phone numbers.

General Information

Prefix (Mr. Mrs., etc.)
Patient First Name
Patient Last Name
Address
Address
City
State
Country
Zip/Postcode
Home Phone
Work Phone
Fax
Email
Occupation

If patient is a minor:

Parent/Guardian Name

What type of lymphatic disease do you have?
Specify (if "Other")
Description of disorder
Date of birth (MM/DD/YYYY)?
Year of onset (YYYY)?
What is your gender?
Are you related to someone with a lymphatic disease?
How are you related to them?

I would like to be contacted about participation in future clinical trials, genetic studies, and tissue/vessel/organ donation program

Please add me to the LRF mailing list - (you will receive the LRF newsletter, solicitation letters semi-annually, invitations to regional events, etc.)