Histiocytosis Association

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	If you respond and have not already registered, you will receive periodic updates and communications from Histiocytosis Association.

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Question - Required - I would like my name, institution, histiocytic disorders I am able to treat, and primary appointment phone number to be displayed on the Histiocytosis Association Physician Finder so that patients around the world can find me for consultation and treatment. If you select no, please continue fill in the remainder of the form, however it will be used for the Association's internal use only and to receive the newsletter:

The Histiocytosis Association developed a Care Bag Program, intended for newly diagnosed patients. Each reusable ‘Histio Warrior’ drawstring bag filled with neccesities and sent to remind histio patients that they are not alone.

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Question - Required - Are you interested in learning more about our Care Bag Program for newly diagnosed patients?

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Question - Required - Your Primary Phone (for the Histiocytosis Association's internal use only):

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Question - Required - Institution/Hospital:

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Question - Required - Department

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Question - Required - Position:

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What is your specialty?: (If there are multiple, please select other and list them separated by a comma).

(Select one of the available choices or enter a different value.)
Question - Required -

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Question - Required - If you are a treating physician, which histiocytic disorders are you willing and able to treat? Pathologists, which histiocytic disorders are you willing and able to diagnose? Please choose all disorders and demographics for each that apply to you:
Please make at least 1 selection from the choices below.

	Erdheim-Chester Disease (ECD) - Adult Patients
	Erdheim-Chester Disease (ECD) - Pediatric Patients
	Diabetes Insipidus (DI)/Arginine Vasopressin Deficiency (AVP-D) - Adult Patients
	Diabetes Insipidus (DI)/Arginine Vasopressin Deficiency (AVP-D) - Pediatric Patients
	Hemophagocytic lymphohistiocytosis (HLH) - Adult Patients
	Hemophagocytic lymphohistiocytosis (HLH) - Pediatric Patients
	Histiocytic Sarcoma (HS) - Adult Patients
	Histiocytic Sarcoma (HS) - Pediatric Patients
	Langerhans cell histiocytosis (LCH) - Adult Patients
	Langerhans cell histiocytosis (LCH) - Pediatric Patients
	Pulmonary Langerhans cell histiocytosis (PLCH) - Adult Patients
	Pulmonary Langerhans cell histiocytosis (PLCH) - Pediatric Patients
	Rosai-Dorfman Disease (RDD) - Adult Patients
	Rosai-Dorfman Disease (RDD) - Pediatric Patients
	Xanthogranuloma (XG) - Adult Patients
	Juvenile Xanthogranuloma (JXG) - Pediatric Patients
	Other histiocytic disorder or related condition

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Question - Required - Approximate number of patients you've treated or are currently treating with histiocytic disorders (pathologists can report number of patients diagnosed):

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Question - Required - Do any of the following describe your institution? (check all that apply)
Please make at least 1 selection from the choices below.

	Histiocytosis Center of Excellence
	NACHO Member (North American Consortium for Histiocytosis)
	ECHO Member (European Consortium for Histiocytosis)
	Comprehensive Care Center
	Has a Histiocytosis Program
	None of the above

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Question - Required - Website where patients can get more information about you, your practice, or your institution. If none, enter "none" or N/A.

(Maximum response 255 chars, approx. 5 rows of text)

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Question - Required - Do you offer telemedicine options?

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Question - Required - Primary Phone for patients to make appointments:

(Maximum response 255 chars, approx. 5 rows of text)

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Question - Required - Are you a Member of the Histiocyte Society?

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Preferred Language(s) - If you speak more than one language, please select 'Other' from the drop-down menu and list all languages spoken with a comma separating each language.

(Select one of the available choices or enter a different value.)
Question - Required -

Question - Not Required - What information are you most interested in?

	Adult Patient Resources
	Awareness & Events
	Caregiver Resources
	For Medical Professionals Only
	Pediatric Patient Resources
	Research & Disease Updates

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Question - Required - Would you like to Go Paperless?

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Question - Required - How did you find out about the Histiocytosis Association?

Healthcare Providers

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