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Your Contact Information: * First Name: Required * Last Name: Required * Email: Required Street 1: Street 2: * City: Required * State / Province: Required AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY AS FM GU MH MP PR PW VI AA AE AP AB BC MB NB NL NS NT NU ON PE QC SK YT None Required ZIP / Postal Code: * Country: Required United States Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivarian Republic of Venezuela Bonaire, Sint Eustatios and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote D'Ivoire Croatia Cuba Curacao Cyprus Czech Republic Democratic People's Republic of Korea The Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Federated States of Micronesia Fiji Finland The Former Yugoslav Republic of Macedonia France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iraq Ireland Islamic Republic of Iran Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory, Occupied Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Plurinational State of Bolivia Poland Portugal Puerto Rico Qatar Republic of Korea Republic of Moldova Reunion Romania Russian Federation Rwanda Saint Barthelemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles S. Georgia & S. Sandwich Isls. Sierra Leone Singapore Sint Maarten (Dutch) Slovakia Slovenia Solomon Islands Somalia South Africa South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syrian Arab Republic Taiwan, Province of China Tajikistan Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United Republic of Tanzania Uruguay USA Minor Outlying Islands Uzbekistan Vanuatu Viet Nam Virgin Islands (British) Virgin Islands (USA) Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Required Yes, I'd like to receive email updates from the Histiocytosis Association. Question - Not Required - Your Primary Phone: Question - Not Required - Your Date of Birth (optional; for birthday communications): Month Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year Year 2039 2038 2037 2036 2035 2034 2033 2032 2031 2030 2029 2028 2027 2026 2025 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 * What is your gender identity? (Select one of the available choices or enter a different value.) Question - Required -What is your gender identity? Click this to indicate that you will select an existing value. Tab to next input." What is your gender identity? Please select response Male Female Non-binary/genderqueer Transgender Genderfluid Agender Two-spirit What is your gender identity? Click this to indicate that you will enter a new value. Tab to next input." What is your gender identity? Provide your answer here * What is your race or ethnicity? (Select one of the available choices or enter a different value.) Question - Required -What is your race or ethnicity? Click this to indicate that you will select an existing value. Tab to next input." What is your race or ethnicity? Please select response Hispanic or Latino Black or African American White Asian Native American or American Indian Pacific Islander What is your race or ethnicity? Click this to indicate that you will enter a new value. Tab to next input." What is your race or ethnicity? Provide your answer here * Your Relationship to Patient: (Select one of the available choices or enter a different value.) Question - Required -Your Relationship to Patient: Click this to indicate that you will select an existing value. Tab to next input." Your Relationship to Patient: Please select response Sibling Grandparent Friend Nurse/Other Healthcare Professional (Non-Physician) Your Relationship to Patient: Click this to indicate that you will enter a new value. Tab to next input." Your Relationship to Patient: Provide your answer here * Diagnosis: (Select one of the available choices or enter a different value.) Question - Required -Diagnosis: Click this to indicate that you will select an existing value. Tab to next input." Diagnosis: Please select response Adult Xanthogranuloma (AXG) Erdheim-Chester Disease (ECD) Hemophagocytic Lymphohistiocytosis - Primary - (pHLH) Hemophagocytic Lymphohistiocytosis - Secondary - (sHLH) Histiocytic Sarcoma (HS) Indeterminate Cell Histiocytosis Interdigitating Cell Sarcoma Juvenile Xanthogranuloma (JXG) Langerhans Cell Histiocytosis (LCH) Langerhans Cell Sarcoma Mixed Histiocytosis (ECD/LCH) Mixed Histiocytosis (ECD/RDD) Mixed Histiocytosis (LCH/RDD) Pulmonary Langerhans Cell Histiocytosis (PLCH) Rosai Dorfman Disease (RDD) Diagnosis: Click this to indicate that you will enter a new value. Tab to next input." Diagnosis: Provide your answer here * Question - Required - Is the patient also affected by Diabetes Insipidus? Please select response Yes No Question - Not Required - Patient First Name: Question - Not Required - Patient Last Name: Question - Not Required - Patient Date of Birth: Month Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year Year 2039 2038 2037 2036 2035 2034 2033 2032 2031 2030 2029 2028 2027 2026 2025 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 * Question - Required - Age of Diagnosis: Please select response Age 17 or younger Age 18 or older Question - Not Required - What information are you most interested in? Adult Patient Resources Awareness & Events Caregiver Resources Pediatric Patient Resources Research & Disease Updates Volunteering * Preferred Language (Select one of the available choices or enter a different value.) Question - Required -Preferred Language Click this to indicate that you will select an existing value. Tab to next input." Preferred Language Please select response Arabic Bengali English French Hindi Italian Mandarin Portuguese Spanish Urdu Preferred Language Click this to indicate that you will enter a new value. Tab to next input." Preferred Language Provide your answer here * Question - Required - Would you like to Go Paperless? Please select response Yes No Spam Control Text: Please leave this field empty
