Care Connector

Healthcare Professional Contact Form

Care Connector offers a valuable opportunity to be listed on the FSHD Society website, helping patients discover more about your services and expertise. If you have experience treating individuals with FSHD, regardless of your specialty, we encourage you to complete our healthcare professionals contact form so families can access the specialized care they need.

Title

First Name *

Last Name *

Personal Email *

Work Email *

Medical Professional Type * Attending Resident Doctor of Osteopathic Medicine Fellow Physician Nurse Nurse Practitioner Other Pharmacist Physical Therapist Physician Physician Assistant Researcher Researcher Physician

Add me to FSHD Society's Care Connector * Yes No

Country * United States Canada Afghanistan 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 Bolivia Bosnia and Herzegovina Botswana Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Curaçao Cyprus Czech Republic Côte d’Ivoire Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland 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 Honduras Hong Kong S.A.R., China Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao S.A.R., China Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Réunion Saint Barthélemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu U.S. Virgin Islands Uganda Ukraine United Arab Emirates United Kingdom United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican Venezuela Viet Nam Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe

Mailing Address

Mailing City

Mailing State/Province Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas United States Minor Outlying Islands US Virgin Islands Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Mailing Zip/Postal Code

Gender * Male Female Other

Name of Practice *

Clinician Office Phone *

Practice Country United States Canada Afghanistan 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 Bolivia Bosnia and Herzegovina Botswana Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Curaçao Cyprus Czech Republic Côte d’Ivoire Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland 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 Honduras Hong Kong S.A.R., China Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao S.A.R., China Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Réunion Saint Barthélemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu U.S. Virgin Islands Uganda Ukraine United Arab Emirates United Kingdom United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican Venezuela Viet Nam Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe

Practice Street Address

Practice City

Practice State Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northwest Territories Nova Scotia Nunavut Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Yukon

Practice Zip/Postal Code

Seeing New Patients? * Yes No

Patient Type * Adults Pediatrics Adults and Pediatrics

Number of Patients with FSHD * 0 1 to 10 10 to 50 50+

Specialty * Agencies Allergy & Immunology Ambulatory Clinic/Facility Anesthesiology Behavioral/Mental Healthcare Cardiology Chiropractor DME Supplier Dentist Dermatology Ear, Nose, & Throat (Otolaryngology) Emergency Medicine Emergency Medicine Technician Endocrinology Gastroenterology Geriatric Medicine Hematology & Oncology Hepatology Hospital Facility Hospitalist Infectious Disease Medicine Licensed Nurse Managed Care Organization Medical Genetics Nephrology Neurology Nuclear Medicine Nursing Home Facility Nursing Related Support Nutritionist/ Dietitian/ Diet Support Obstetrics & Gynecology Ophthalmology Optometrist Orthopedic Surgery Other Pain Medicine Pathology Pediatric Medicine Pharmacist Phlebology Physical Medicine & Rehabilitation Physical Therapist Physician Assistant/Nurse Practitioner/Registered Nurse Plastic Surgery Podiatry Preventive Medicine Primary Care Physician Psychiatry Psychology Pulmonology Radiation Oncology Radiology & Imaging Respiratory/Rehabilitation Therapy & Support Rheumatology Specialist Speech/Language/Hearing Surgery Surgical Oncology Technicians, Various Urology

Specific Muscular Dystrophy Followed (Select all that apply) * Becker Muscular Dystrophy (BMD)Congenital Muscular DystrophyDuchenne Muscular Dystrophy (DMD)Distal Muscular DystrophyEmery-Dreifuss Muscular DystrophyFacioscapulohumeral Muscular Dystrophy (FSHD)Limb-Girdle Muscular Dystrophy (LGMD)Myotonic DystrophyOculopharyngeal Muscular Dystrophy7-Dehydrocholesterol Reductase Deficiency

Spoken Languages (Select all that apply) ArabicArmenianBengaliCantoneseChineseCzechDutch (Belgium)Dutch (Netherlands)EnglishFrenchGerman GreekGujaratiHaitian CreoleHebrew (modern)HindiHungarianItalianJapaneseKhmerKoreanMandarinNavajoPersianPolishPortuguesePortuguese (Brazil)PunjabiRussianSerbianSpanishSwedishTamilTeluguUrduVietnameseYiddish

Credentials

Board Certifications

Degree(s)

Additional Notes

Would you like to receive information on resources for medical professionals, including CME opportunities, conferences, research updates, and other events? * Yes No

Comments

Your participation is critical to finding treatments and a cure for FSHD! The FSHD Society will not share the information you provide with any third parties and we protect your data using the most current security algorithm. By completing the form you are opting into emails from the FSHD Society. You can unsubscribe anytime. For details, please review our Privacy Policy.