Patient Membership

Become a Patient Member of NUCDF

Membership Information and Application

We're happy you are joining us in the fight to conquer urea cycle disorders. NUCDF is a volunteer non-profit organization of families, friends, and medical professionals dedicated to the identification, treatment, and cure of Urea Cycle Disorders. Our vision is a world where no child or adult suffers from UCD. The benefits of membership are priceless - you can help save lives and make breakthroughs possible.

As a patient member of NUCDF, you will also receive a thank you card with a small keepsake item and our monthly e-newsletter as well as personalized support if needed.

Sharing information on this form about your experiences with the disorder helps the understanding of outcomes and prevalence of the disorders, and helps focus research efforts.

Please complete the following information and press "Submit Form" to transmit the information. If you'd like to mail this form, please print this form and mail it to:

NUCDF
75 S. Grand Ave.
Pasadena, CA 91105

Please note: NUCDF takes your privacy very seriously. We will never release information to any outside party without your explicit written consent.

Name

First Name *

Last Name *

Address

Country

Address Line 1

Address Line 2

City

State/Province

Postal Code

Home Phone

Work Phone

Family - Disorder

Email address for Newsletter

Completing the following questionnaire is optional. However, it will assist us in understanding and supporting the needs of our urea cycle families and determining prevalence and outcome of the disorders.

A. Do you have a child that has been diagnosed with a Urea Cycle Disorder?

If you answered 'Yes' to question A, please proceed to question B. If you answered 'No', why have you decided to join the NUCDF?

B. Please complete the following information regarding all of your children, including those not affected by UCDs:

Child #1

Type of Disorder:

Age at Time of Diagnosis:

Is this child Living?

Current Age:

Date of Birth:

Year of Death

Age at Death:

Cause of Death:

Child #2

Type of Disorder:

Age at Time of Diagnosis:

Is this child Living?

Current Age:

Date of Birth:

Year of Death

Age at Death:

Cause of Death:

Child #3

Type of Disorder:

Age at Time of Diagnosis:

Is this child Living?

Current Age:

Date of Birth:

Year of Death

Age at Death:

Cause of Death:

If you have been diagnosed with a urea cycle disorder:

Type of Disorder:

Age at Diagnosis:

Current Age:

Our goal is to educate medical professionals and provide update information about new treatments, tests, etc. Please provide your physician's contact information to be included on the physician mailing list:

D. Name of treating geneticist/metabolic specialist:

Name

First Name

Last Name

Title

Department

University/Hospital

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Address

Country

Address Line 1

Address Line 2

City

State/Province

Postal Code

Phone

Fax

Web Site

Subscribe to our email newsletter?

Yes, I want to subscribe to your email newsletter.

Patient Membership

Become a Patient Member of NUCDF

Membership Information and Application

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