INDIVIDUAL MEMBERSHIP PRE-APPLICATION

1. NAME SURNAME *
2. PHONE NUMBER *
3. E-MAİL ADDRESS *
4. THE CITY WHICH YOU ARE LIVING *
5. DIAGNOSIS OF DIAGNOSIS / SYNDROME *
6. WHAT IS THE INDUCTION OF YOUR DISEASE / SYNDROME? *
7. ARE YOU ASSOCIATED WITH PATIENTS IF YOU ARE PATIENTS? WHAT ARE YOUR NEIGHBORHOOD OF NEAR THE PATIENTS? *
8. DO YOU HAVE A PATIENT ASSOCIATION? (NATIONAL OR INTERNATIONAL) *
9. WHAT IS THE BIGGEST SIKINTI YOU HAVE BEEN LIKE? *
10. WHAT IS YOUR EMERGENCY REQUEST? *
11. I ACKNOWLEDGE AND ACKNOWLED THAT I HAVE ACKNOWLEDGED THE COMMUNICATION OF THE PERSONAL DATA THAT I GIVEN TO THE NETWORK FOR RESEARCH, SERVICES AND WORKING ON ITS IMPLEMENTATION. *
     
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