Registration – Instituto Reconvexo

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Registration – Instituto Reconvexo

Registration

If you are a person living or coexisting (friends, partners, relatives, associates) with Leber’s Hereditary Optic Neuropathy – LHON, or if you want to be a part of our network, make your registration! We want to know you a little more!

01. Name or Preferred Name

02. Email

03. State

04. City

05. Telephone

06. Date of birth

07. Gender
MaleFemaleTrans (or non-binary)

08. Are you a person living or coexisting with Leber’s Hereditary Optic Neuropathy – LHON?

09. If not, what is your relationship with Leber’s Hereditary Optic Neuropathy – LHON?

10. If yes, which genetic variation?

11. Do you have LHON Plus symptoms?

12. If yes, which ones?

13. Are you on any treatment?

14. Which medicine do you use?

15. In case you use another medicine, specify which one:

16. Do you have a medical follow-up with a neuro-ophthalmologist?

17. If you have a medical follow-up, indicate in which city:

18. Testimony

Contact

Reconvexo Institute

reconvexo@ireconvexo.com.br

+55 (11) 99547-3306

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