Sign-Up Sheet: One-on-One Consultations with the Experts

Limited individual, one-on-one sessions with the expert physicians onhand at the 2010 Neutropenia Family Conference will again be available. Unfortunately not every request can be filled. To be considered, we need the following information to give to the physicians and for selection review. Selection criteria will hinge on a first come/first serve basis as well as the severity of the need for the consultation, and as deemed by the experts.

Name of Patient (required):
Your Name (if different from above):
Relation to the patient:
Email (required):
Current Age of SCN patient:
Age at onset of symptoms:
Type of SCN:	Congenital Cyclic Idiopathic Autoimmune Unknown
Have you ever met with any of the attending experts in the past?	Yes No
if yes, when? (date):
Is the patient currently seeing a hematologist?	Yes No
Dr.'s Name:
Dr.'s City:
Dr.'s State:
Any current treatments(i.e. Neupogen, etc, please include dose):
Main concern you would like to discuss:
Please include any other information you deem of importance:

Please submit this form as soon as possible. It is best to submit with your registration form, if possible.

You will be notified if more information is necessary.

Every effort will be made to accommodate as many requests as possible.