Contact Information

First Name

Last Name

Cell Phone

Home Phone

Question

Topic

Subject

Question:

This form is monitored by our on-staff nurse and is intended for medical and mental health questions related to Marfan, VEDS, LDS, and related conditions.

For general inquires/to get in touch with a Marfan staff member on non-medical topics, please visit the contact us form under About Us.

Demographic Information

Please tell us a little more about yourself to help us better serve you.

My question is regarding someone other than myself

Gender

Date of birth

I am affected by:

Please provide YOUR information. If your question is about another person, please choose "I am not affected" and select "my question is about someone else" below to provide their information.

My diagnosis is:

My question is about my:

They are affected by:

Medical/Professional Specialty (if applicable)

Mailing Address

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Provinces

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Phone Number