KCNB1 Registry Questionnaire

* Indicates required field

KCNB1 Warrior's Name *

First

Last

KCNB1 Warrior's DOB *

Parent 1 Name *

First

Last

Parent 2 Name *

First

Last

Sibling Name *

First

Last

Sibling DOB *

Sibling Name *

First

Last

Sibling DOB *

Sibling Name *

First

Last

Sibling DOB *

Sibling Name *

First

Last

Sibling DOB *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Email 2 *

Phone Number *

KCNB1 Variant (if known) *

Date and Place of Diagnosis / Where Treated *

Any other information you'd like to provide *

Submit