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Registration for participation in InterRett

Please provide the following details. We will then email/send you an information sheet, consent form and login details to participate in this exciting project.



First name:   

Surname:   

Name of individual with the disorder:   

Has your child been tested for a mutation?

Yes, has MECP2  Yes, has CDKL5  Yes, result unknown  Not tested  

Their date of birth:

      

Your contact details:

Address:Street:   

Suburb:   

State:   

Country:

Zip code:   

Telephone - home:   

Telephone - business:   

Telephone - mobile:   

Email:   

How did you hear about InterRett?

InterRett website

Other website

Conference

Family gathering

Rett syndrome magazine

Other

Which version of the family questionnaire would you like to complete?

Online version  Paper version