Please Note: The purpose of this form is to gather information to be presented to a Physician to be looked over for research. This is to try and help physicians find better treatments for our loved ones. Your information will be kept completely confidential and only used for reasons stated above. If you have questions email us at email@example.com .
Thank you so much for taking the time to answer the above questions. And for participating in helping our voices to be heard for the sake of our loved ones. Also for giving us the strength to make a difference.
Please note that your information will only go to a Physician for purposes of research. We have had many request for this information. We will not release this information other than the above stated. If you have questions please feel free to contact us. Again thank-you for your help and support.