Parent Patient Submission Form

Details of applicant making the submission:

Full Name:
First Name (required)

Last Name (required)

Title (required)

Name of Patient if Different:

First Name

Last Name

Title:

Treating Hospital (required)

Diagnosis (required)

Disorder Type
Please make at least 1 selection from the choices below.:

Erdheim-Chester Disease (ECD) - Adult PatientsErdheim-Chester Disease (ECD) - Paediatric PatientsDiabetes Insipidus (DI)/Arginine Vasopressin Deficiency (AVP-D) - Adult PatientsDiabetes Insipidus (DI)/Arginine Vasopressin Deficiency (AVP-D) - Paediatric PatientsHemophagocytic lymphohistiocytosis (HLH) - Adult PatientsHemophagocytic lymphohistiocytosis (HLH) - Paediatric PatientsHistiocytic Sarcoma (HS) - Adult PatientsHistiocytic Sarcoma (HS) - Paediatric PatientsLangerhans cell histiocytosis (LCH) - Adult PatientsLangerhans cell histiocytosis (LCH) - Paediatric PatientsPulmonary Langerhans cell histiocytosis (PLCH) - Adult PatientsPulmonary Langerhans cell histiocytosis (PLCH) - Paediatric PatientsRosai-Dorfman Disease (RDD) - Adult PatientsRosai-Dorfman Disease (RDD) - Paediatric PatientsXanthogranuloma (XG) - Adult PatientsJuvenile Xanthogranuloma (JXG) - Paediatric PatientsOther histiocytic disorder or related condition

Age (Required)

Gender:

Your Email (required)

Street 1:

Street 2:

City (Required):

County (Required):

Post Code (Required):

Country (Required):

Primary Phone (for Histio UK internal use only. Required):

QUESTION (NO MORE THAN 250 WORDS)