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Your Contact Details

Email Address

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Mothers First Name

*

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Mothers Last Name

*

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Fathers First Name

*

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Fathers Last Name

*

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Name of the person with Costello Syndrome

*

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Date of birth (day/month/year)

*

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House Number

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Address Line 1

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Address Line 2

City

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Zip / Post code

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Phone number

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State/Province (US/Canada only)

Country

About the person diagnosed with Costello Syndrome

The name of the doctor who diagnosed CS

Age when diagnoses took place

Name and address of Center where CS was diagnosed. If Known

A simple genetic test can be carried out to confirm the diagnosis of Costello Syndrome, It is important for this test to be done to aid diagnosis, treatments and therapy.

Has a gene test been done to confirm the diagnosis?

*

yes no Required

If the diagnosis has not been confirmed by testing, Please visit Genetests for more Information

Do you know the outcome of the test?

yes no

There are several Mutations of HRAS gene that are known to cause CS. If Known please tell us which it is.

Please let us know the ages of the parents when the Person with Costello syndrome was born

Mothers age

*

Required

Fathers age

*

Required

CostelloKids is about the whole family Could you please tell us about the CS persons Siblings

Do you have any other children in your family?

yes no

If the answer to the above question is yes. Could you please list the childrens names and birthdate's

Would you like to join our E-mail discussion list ?

yes no

Comments:
Please enter anything else you would like to tell us about yourself.

Join the International Costello Syndrome Support Group