RECEIVE INFORMATION ON THE PATIENT REGISTRY

Your Name (required) Your Email (required) Name of Person with Xia-Gibbs Syndrome Diagnosis (required) Age of Person with Xia-Gibbs Syndrome Diagnosis (required) City/Country of person with Xia-Gibbs Syndrome Diagnosis (required) Your relationship to person with XGS (eg Mother/Father/Doctor/Other) (required) Date of Diagnosis Diagnosing Physician's Name and Institution