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I would like to receive my initial packet of information by:* Relationship to Ectodermal Dysplasia:* Please Select One Individual Affected by Ectodermal Dysplasia Parent of Affected Individual Extended Family Member of Affected Individual Friend of Affected Individual Medical or Dental Professional Other
Please Specify Relationship:
Type of Ectodermal Dysplasia:* Please Select One Hypohidrotic Ectodermal Dysplasia (HED) Ectrodactyly-Ectodermal Dysplasia-Clefting EEC Syndrome Clouston Syndrome Ankyloblepharon-Ectodermal Dysplasia-Clefting (AEC) Syndrome Witkop Tooth Nail Syndrome Focal Dermal Hypoplasia (Goltz Syndrome) Fried Tooth Nail Syndrome Incontinentia Pigmenti (IP) Trichorhinophalangeal (TRP) Syndrome, Types I & II Trichodentoosseous (TDO) Syndrome Oculodentodigital Dysplasia (ODD) Other
Please Specify Type:*
Genetic Mutation Please Select One Unknown ATP6V1B2 AXIN2 CDH1 CDH3 CHUK COL11A1 CTNND1 DKC1 DOCK8 DSP EDA EDA2R EDAR EDARADD ERCC2 ERCC3 EVC EVC2 FOXI3 FRAS1 FREM1 FREM2 GJB2 GJB6 GREM2 GRHL2 GRHL3 GTF2H5 HOXC13 HR IFT122 IFT43 IKBKG JUP KAT6B KDF1 KLF4 KREMEN1 KRT1 KRT14 KRT16 KRT74 KRT85 KRT9 LEF1 LIPH LRP6 LSS LTBP3 MBTPS2 MSX1 NECTIN1 NECTIN4 NFKB1 NFKBIA ORAI1 PAX9 PIGL PKP1 PLCD1 PORCN PTH1R REL RELA RELB SMARCAD1 TP63 TRAF6 TSPEAR TWIST2 WDR35 WNT10A WNT10B ZNF750
Date of Birth:*
MM slash DD slash YYYY
Ethnicity* NFED is committed to fair representation of the ectodermal dysplasia community. Knowing the answers to these questions will help achieve this commitment.
Please Select One American Indian or Alaska Native(Eg: Navajo nation, Blackfeet tribe, Mayan, Aztec, Native Village or Barrow Inupiat Traditional Government, Nome Eskimo Community, etc) Asian (Eg: Chinese, Filipino, Asian Indian, Vietnamese, Korean, Japanese, etc) Black or African American (Eg: African American, Jamaican, Haitian, Nigerian, Ethiopian, Somalian, etc) Hispanic, Latino or Spanish origin (Eg: Mexican or Mexican American, Puerto Rican, Cuban, Salvadoran, Dominican, Colombian, etc) Middle Eastern or North African (Eg: Lebanese, Iranian, Egyptian, Syrian, Moroccan, Algerian, etc) Native Hawaiian or Other Pacific Islander (Eg: Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, etc) White (Eg: German, Irish, English, Italian, Polish, French, etc) Some other race, ethnicity or origin I prefer not to answer
Are there other members of your family that are also affected by ectodermal dysplasia?* Number of Children or Additional Family Members Affected:* Please Select a Number 1 2 3 4 5
Name of Person Affected:*
First
Last
Ethnicity* NFED is committed to fair representation of the ectodermal dysplasia community. Knowing the answers to these questions will help achieve this commitment.
Please Select One American Indian or Alaska Native(Eg: Navajo nation, Blackfeet tribe, Mayan, Aztec, Native Village or Barrow Inupiat Traditional Government, Nome Eskimo Community, etc) Asian (Eg: Chinese, Filipino, Asian Indian, Vietnamese, Korean, Japanese, etc) Black or African American (Eg: African American, Jamaican, Haitian, Nigerian, Ethiopian, Somalian, etc) Hispanic, Latino or Spanish origin (Eg: Mexican or Mexican American, Puerto Rican, Cuban, Salvadoran, Dominican, Colombian, etc) Middle Eastern or North African (Eg: Lebanese, Iranian, Egyptian, Syrian, Moroccan, Algerian, etc) Native Hawaiian or Other Pacific Islander (Eg: Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, etc) White (Eg: German, Irish, English, Italian, Polish, French, etc) Some other race, ethnicity or origin I prefer not to answer
Type of Ectodermal Dysplasia:* Please Select One Hypohidrotic Ectodermal Dysplasia (HED) Ectrodactyly-Ectodermal Dysplasia-Clefting (EEC) Syndrome Clouston Syndrome Ankyloblepharon-Ectodermal Dysplasia-Clefting (AEC) Syndrome Witkop Tooth Nail Syndrome Focal Dermal Hypoplasia (Goltz Syndrome) Fried Tooth Nail Syndrome Incontinentia Pigmenti (IP) Trichorhinophalangeal (TRP) Syndrome, Types I & II Trichodentoosseous (TDO) Syndrome Oculodentodigital Dysplasia (ODD) Other
Please Specify Type:*
Genetic Mutation Please Select One Unknown ATP6V1B2 AXIN2 CDH1 CDH3 CHUK COL11A1 CTNND1 DKC1 DOCK8 DSP EDA EDA2R EDAR EDARADD ERCC2 ERCC3 EVC EVC2 FOXI3 FRAS1 FREM1 FREM2 GJB2 GJB6 GREM2 GRHL2 GRHL3 GTF2H5 HOXC13 HR IFT122 IFT43 IKBKG JUP KAT6B KDF1 KLF4 KREMEN1 KRT1 KRT14 KRT16 KRT74 KRT85 KRT9 LEF1 LIPH LRP6 LSS LTBP3 MBTPS2 MSX1 NECTIN1 NECTIN4 NFKB1 NFKBIA ORAI1 PAX9 PIGL PKP1 PLCD1 PORCN PTH1R REL RELA RELB SMARCAD1 TP63 TRAF6 TSPEAR TWIST2 WDR35 WNT10A WNT10B ZNF750
Date of Birth:*
MM slash DD slash YYYY
Relationship to You:*
Name of Person Affected:*
First
Last
Ethnicity* NFED is committed to fair representation of the ectodermal dysplasia community. Knowing the answers to these questions will help achieve this commitment.
Please Select One American Indian or Alaska Native(Eg: Navajo nation, Blackfeet tribe, Mayan, Aztec, Native Village or Barrow Inupiat Traditional Government, Nome Eskimo Community, etc) Asian (Eg: Chinese, Filipino, Asian Indian, Vietnamese, Korean, Japanese, etc) Black or African American (Eg: African American, Jamaican, Haitian, Nigerian, Ethiopian, Somalian, etc) Hispanic, Latino or Spanish origin (Eg: Mexican or Mexican American, Puerto Rican, Cuban, Salvadoran, Dominican, Colombian, etc) Middle Eastern or North African (Eg: Lebanese, Iranian, Egyptian, Syrian, Moroccan, Algerian, etc) Native Hawaiian or Other Pacific Islander (Eg: Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, etc) White (Eg: German, Irish, English, Italian, Polish, French, etc) Some other race, ethnicity or origin I prefer not to answer
Type of Ectodermal Dysplasia:* Please Select One Hypohidrotic Ectodermal Dysplasia (HED) Ectrodactyly-Ectodermal Dysplasia-Clefting (EEC) Syndrome Clouston Syndrome Ankyloblepharon-Ectodermal Dysplasia-Clefting (AEC) Syndrome Witkop Tooth Nail Syndrome Focal Dermal Hypoplasia (Goltz Syndrome) Fried Tooth Nail Syndrome Incontinentia Pigmenti (IP) Trichorhinophalangeal (TRP) Syndrome, Types I & II Trichodentoosseous (TDO) Syndrome Oculodentodigital Dysplasia (ODD) Other
Please Specify Type:*
Genetic Mutation Please Select One Unknown ATP6V1B2 AXIN2 CDH1 CDH3 CHUK COL11A1 CTNND1 DKC1 DOCK8 DSP EDA EDA2R EDAR EDARADD ERCC2 ERCC3 EVC EVC2 FOXI3 FRAS1 FREM1 FREM2 GJB2 GJB6 GREM2 GRHL2 GRHL3 GTF2H5 HOXC13 HR IFT122 IFT43 IKBKG JUP KAT6B KDF1 KLF4 KREMEN1 KRT1 KRT14 KRT16 KRT74 KRT85 KRT9 LEF1 LIPH LRP6 LSS LTBP3 MBTPS2 MSX1 NECTIN1 NECTIN4 NFKB1 NFKBIA ORAI1 PAX9 PIGL PKP1 PLCD1 PORCN PTH1R REL RELA RELB SMARCAD1 TP63 TRAF6 TSPEAR TWIST2 WDR35 WNT10A WNT10B ZNF750
Date of Birth:*
MM slash DD slash YYYY
Relationship to You:*
Name of Person Affected:*
First
Last
Ethnicity* NFED is committed to fair representation of the ectodermal dysplasia community. Knowing the answers to these questions will help achieve this commitment.
Please Select One American Indian or Alaska Native(Eg: Navajo nation, Blackfeet tribe, Mayan, Aztec, Native Village or Barrow Inupiat Traditional Government, Nome Eskimo Community, etc) Asian (Eg: Chinese, Filipino, Asian Indian, Vietnamese, Korean, Japanese, etc) Black or African American (Eg: African American, Jamaican, Haitian, Nigerian, Ethiopian, Somalian, etc) Hispanic, Latino or Spanish origin (Eg: Mexican or Mexican American, Puerto Rican, Cuban, Salvadoran, Dominican, Colombian, etc) Middle Eastern or North African (Eg: Lebanese, Iranian, Egyptian, Syrian, Moroccan, Algerian, etc) Native Hawaiian or Other Pacific Islander (Eg: Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, etc) White (Eg: German, Irish, English, Italian, Polish, French, etc) Some other race, ethnicity or origin I prefer not to answer
Type of Ectodermal Dysplasia:* Please Select One Hypohidrotic Ectodermal Dysplasia (HED) Ectrodactyly-Ectodermal Dysplasia-Clefting (EEC) Syndrome Clouston Syndrome Ankyloblepharon-Ectodermal Dysplasia-Clefting (AEC) Syndrome Witkop Tooth Nail Syndrome Focal Dermal Hypoplasia (Goltz Syndrome) Fried Tooth Nail Syndrome Incontinentia Pigmenti (IP) Trichorhinophalangeal (TRP) Syndrome, Types I & II Trichodentoosseous (TDO) Syndrome Oculodentodigital Dysplasia (ODD) Other
Please Specify Type:*
Genetic Mutation Please Select One Unknown ATP6V1B2 AXIN2 CDH1 CDH3 CHUK COL11A1 CTNND1 DKC1 DOCK8 DSP EDA EDA2R EDAR EDARADD ERCC2 ERCC3 EVC EVC2 FOXI3 FRAS1 FREM1 FREM2 GJB2 GJB6 GREM2 GRHL2 GRHL3 GTF2H5 HOXC13 HR IFT122 IFT43 IKBKG JUP KAT6B KDF1 KLF4 KREMEN1 KRT1 KRT14 KRT16 KRT74 KRT85 KRT9 LEF1 LIPH LRP6 LSS LTBP3 MBTPS2 MSX1 NECTIN1 NECTIN4 NFKB1 NFKBIA ORAI1 PAX9 PIGL PKP1 PLCD1 PORCN PTH1R REL RELA RELB SMARCAD1 TP63 TRAF6 TSPEAR TWIST2 WDR35 WNT10A WNT10B ZNF750
Date of Birth:*
MM slash DD slash YYYY
Relationship to You:*
Name of Person Affected:*
First
Last
Ethnicity* NFED is committed to fair representation of the ectodermal dysplasia community. Knowing the answers to these questions will help achieve this commitment.
Please Select One American Indian or Alaska Native(Eg: Navajo nation, Blackfeet tribe, Mayan, Aztec, Native Village or Barrow Inupiat Traditional Government, Nome Eskimo Community, etc) Asian (Eg: Chinese, Filipino, Asian Indian, Vietnamese, Korean, Japanese, etc) Black or African American (Eg: African American, Jamaican, Haitian, Nigerian, Ethiopian, Somalian, etc) Hispanic, Latino or Spanish origin (Eg: Mexican or Mexican American, Puerto Rican, Cuban, Salvadoran, Dominican, Colombian, etc) Middle Eastern or North African (Eg: Lebanese, Iranian, Egyptian, Syrian, Moroccan, Algerian, etc) Native Hawaiian or Other Pacific Islander (Eg: Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, etc) White (Eg: German, Irish, English, Italian, Polish, French, etc) Some other race, ethnicity or origin I prefer not to answer
Type of Ectodermal Dysplasia:* Please Select One Hypohidrotic Ectodermal Dysplasia (HED) Ectrodactyly-Ectodermal Dysplasia-Clefting (EEC) Syndrome Clouston Syndrome Ankyloblepharon-Ectodermal Dysplasia-Clefting (AEC) Syndrome Witkop Tooth Nail Syndrome Focal Dermal Hypoplasia (Goltz Syndrome) Fried Tooth Nail Syndrome Incontinentia Pigmenti (IP) Trichorhinophalangeal (TRP) Syndrome, Types I & II Trichodentoosseous (TDO) Syndrome Oculodentodigital Dysplasia (ODD) Other
Please Specify Type:*
Genetic Mutation Please Select One Unknown ATP6V1B2 AXIN2 CDH1 CDH3 CHUK COL11A1 CTNND1 DKC1 DOCK8 DSP EDA EDA2R EDAR EDARADD ERCC2 ERCC3 EVC EVC2 FOXI3 FRAS1 FREM1 FREM2 GJB2 GJB6 GREM2 GRHL2 GRHL3 GTF2H5 HOXC13 HR IFT122 IFT43 IKBKG JUP KAT6B KDF1 KLF4 KREMEN1 KRT1 KRT14 KRT16 KRT74 KRT85 KRT9 LEF1 LIPH LRP6 LSS LTBP3 MBTPS2 MSX1 NECTIN1 NECTIN4 NFKB1 NFKBIA ORAI1 PAX9 PIGL PKP1 PLCD1 PORCN PTH1R REL RELA RELB SMARCAD1 TP63 TRAF6 TSPEAR TWIST2 WDR35 WNT10A WNT10B ZNF750
Date of Birth:*
MM slash DD slash YYYY
Relationship to You:*
Name of Person Affected:*
First
Last
Ethnicity* NFED is committed to fair representation of the ectodermal dysplasia community. Knowing the answers to these questions will help achieve this commitment.
Please Select One American Indian or Alaska Native(Eg: Navajo nation, Blackfeet tribe, Mayan, Aztec, Native Village or Barrow Inupiat Traditional Government, Nome Eskimo Community, etc) Asian (Eg: Chinese, Filipino, Asian Indian, Vietnamese, Korean, Japanese, etc) Black or African American (Eg: African American, Jamaican, Haitian, Nigerian, Ethiopian, Somalian, etc) Hispanic, Latino or Spanish origin (Eg: Mexican or Mexican American, Puerto Rican, Cuban, Salvadoran, Dominican, Colombian, etc) Middle Eastern or North African (Eg: Lebanese, Iranian, Egyptian, Syrian, Moroccan, Algerian, etc) Native Hawaiian or Other Pacific Islander (Eg: Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, etc) White (Eg: German, Irish, English, Italian, Polish, French, etc) Some other race, ethnicity or origin I prefer not to answer
Type of Ectodermal Dysplasia:* Please Select One Hypohidrotic Ectodermal Dysplasia (HED) Ectrodactyly-Ectodermal Dysplasia-Clefting (EEC) Syndrome Clouston Syndrome Ankyloblepharon-Ectodermal Dysplasia-Clefting (AEC) Syndrome Witkop Tooth Nail Syndrome Focal Dermal Hypoplasia (Goltz Syndrome) Fried Tooth Nail Syndrome Incontinentia Pigmenti (IP) Trichorhinophalangeal (TRP) Syndrome, Types I & II Trichodentoosseous (TDO) Syndrome Oculodentodigital Dysplasia (ODD) Other
Please Specify Type:*
Genetic Mutation Please Select One Unknown ATP6V1B2 AXIN2 CDH1 CDH3 CHUK COL11A1 CTNND1 DKC1 DOCK8 DSP EDA EDA2R EDAR EDARADD ERCC2 ERCC3 EVC EVC2 FOXI3 FRAS1 FREM1 FREM2 GJB2 GJB6 GREM2 GRHL2 GRHL3 GTF2H5 HOXC13 HR IFT122 IFT43 IKBKG JUP KAT6B KDF1 KLF4 KREMEN1 KRT1 KRT14 KRT16 KRT74 KRT85 KRT9 LEF1 LIPH LRP6 LSS LTBP3 MBTPS2 MSX1 NECTIN1 NECTIN4 NFKB1 NFKBIA ORAI1 PAX9 PIGL PKP1 PLCD1 PORCN PTH1R REL RELA RELB SMARCAD1 TP63 TRAF6 TSPEAR TWIST2 WDR35 WNT10A WNT10B ZNF750
Date of Birth:*
MM slash DD slash YYYY
Relationship to You:*
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