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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
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Type of Ectodermal Dysplasia:* Please Select One ADULT Syndrome (ADULT); Acro-Dermato-Ungual-Lacrimal-Tooth Syndrome; TP63 AEC Syndrome; Ankyloblepharon-Ectodermal Defects-Cleft Lip/Palate (AEC); Hay-Wells Syndrome; Rapp-Hodgkin Syndrome; TP63 Clouston Syndrome (ECTD2); Ectodermal Dysplasia, Hidrotic (HED2); GJB6 Ectodermal Dysplasia 10A, Autosomal Dominant HED (ECTD10A); EDAR Ectodermal Dysplasia 10B, Autosomal Recessive HED (ECTD10B); EDAR Ectodermal Dysplasia 11A, Autosomal Dominant HED (ECTD11A); EDARADD Ectodermal Dysplasia 11B, Autosomal Recessive HED (ECTD11B); EDARADD Ectodermal Dysplasia 14, Hair/Tooth Type (ECTD14); TSPEAR Ectodermal Dysplasia and Immunodeficiency 1 (EDAID1); (HED-ID); (OLEDAID); (XHMED); IKBKG Ectodermal Dysplasia and Immunodeficiency 2 (HED-ID2); (EDAID2); NFKBIA EEC Syndrome 3 (EEC); Ectrodactyly-Ectodermal Dysplasia-Cleft Lip/Palate Syndrome; TP63 Goltz Syndrome; Goltz-Gorlin Syndrome; PORCN-Related Developmental Disorders; Focal Dermal Hypoplasia (FDH); PORCN Incontinentia Pigmenti (IP); Bloch-Sulzberger Syndrome; IKBKG Langer-Giedion Syndrome (TRPS2); Trichorhinophalangeal Syndrome, Type II; Chromosome 8q24.1 Deletion Syndrome; EXT1; TRPS1 Odonto-Onycho-Dermal Dysplasia (OODD); WNT10A Schopf-Schulz-Passarge Syndrome (SSPS); WNT10A Tricho-Dento-Osseous Syndrome (TDO); TDO Syndrome; DLX3 Trichorhinophalangeal Syndrome, Type I (TRPS1); TRPS1 Witkop Syndrome (ECTD3); Tooth-and-Nail Syndrome (TNS); MSX1 X-linked Hypohidrotic Ectodermal Dysplasia (XLHED); Christ-Siemens-Touraine Syndrome; Ectodermal Dysplasia, Hypohidrotic, 1 (HED1); EDA Ectodermal Dysplasia - Type Unknown Other
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Genetic Mutation Please Select One Unknown AP1B1 CDH3 CHUK CST6 DLX3 EDA EDA2R EDAR EDARADD EVC EVC2 GJA1 GJB2 GJB6 GRHL2 HOXC13 IKBKG KDF1 KREMEN1 KRT74 KRT85 LEF1 LRP6 MSX1 NFKBIA PKP1 PORCN PRKD1 PVRL1 PVRL4 RHOA RIPK4 TBX3 TP63 TRAF6 TRPS1 TRPS1 + EXT1 TSPEAR TWIST2 WNT10A
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 GJA1 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 WDR19 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 GJA1 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 WDR19 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 GJA1 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 WDR19 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 GJA1 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 WDR19 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 GJA1 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 WDR19 WDR35 WNT10A WNT10B ZNF750
Date of Birth:*
MM slash DD slash YYYY
Relationship to You:*
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