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