Leukodystrophy Center Online Referral Form

The Leukodystrophy Center at Children's Hospital of Philadelphia offers various clinical and research options that may be of interest to your family. Please indicate which of these opportunities you would like to learn more about. You may also select "Unsure" and enter specific questions or concerns in the pop-up box. Our team will work closely with you to identify the most appropriate resources.

Clinical

Research

Clinical & Research

Unsure

What is Your First Name?

What is your Last Name?

What is your relationship to the individual being referred to our program?

Are you legally authorized to make medical decisions on behalf of this individual?

What is your birthdate?

This information will be needed for registration purposes

What is your address?

Country

State

Street Address

City

Postal / Zip Code

Please provide the best phone number to contact you:

Numbers only please!

Please list the best email address to contact you:

What is your preferred language?

Individual's First Name being referred to the program

Individual's Last Name

Date of Birth

What is the individual's place of birth?

City and Country as listed on birth Certificate

What is the individual's gender?

What race best describes the individual?

When did the individual first begin experiencing symptoms?

An approximate date is acceptable!

Have they had an MRI in the past?

Yes

Please indicate where the MRI studies were performed.

Do they have a confirmed diagnosis?

Yes

What is the diagnosis?

Has the individual had genetic testing?

Yes

Unsure

Does the individual have any similarly affected family member?

Yes

If you are interested in referring this individual’s affected sibling(s), please submit an separate Online Referral Form for each additional sibling using the same link.

Please provide a list of physicians who have provided care for this individual.This information will help our coordinators collect medical records on your behalf. If possible, include the physician's name, specialty, and affiliated hospital/clinic.

Please tell us how you heard about our team.

If Other is chosen, please describe:

Find a research study

Innovation and your child

Find research studies

Leukodystrophy Center Online Referral Form