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Patient Matching Registration Form

Today's Date
PLEASE TELL US ABOUT THE PATIENT
Name*
First Last
Date of Birth*
MM
DD
YYYY
Gender*
- Male
- Female
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Email*
What is the patient's diagnosis?*
- lymphangiomatosis
- Gorham's Disease
- Lymphatic Malformation
- Other or not sure
What areas of the patient's body are effected? Check all that apply:*
- Chest
- Abdomen
- Bones
- Skin
What symptoms have been experienced? Check all that apply.*
- Pain
- Fluid Collection(s)
- Fracture
- Cough/wheezing/difficulty breathing
- Severe fatigue (patient unable to attend school/work/activities at least once a week)
- slow growth/malnourishment
- Fever not associated with acute illness
- Frequent infection
- Nausea/Vomiting
- Diarrhea
- Rash
- None of the above
What is the name of the patient's main doctor for lymphangiomatosis/Gorham's disease?
What is this doctor's area of specialty?
please select from the drop-down menu
Please enter the name of the clinic/hospital where the patient receives most of his/her care for lymphangiomatosis/Gorham's*
Please include the city and state where this facility is located.
ABOUT THE PERSON COMPLETING THE FORM
Name of person completing form*
First Last
I am the:*
- Patient
- Parent or Legal Guardian with whom the patient resides
- Parent or Guardian with whom the patient does NOT reside
- Spouse of the patient
- other

Reach for a Cure

Register a patient in the International LGDA Registry for Lymphatic Malformations. Help researchers worldwide unlock the mysteries of lymphangiomatosis and Gorham's disease to find a treatment and a cure!

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LGDA is here to help you find resources and to provide support to patients and families living with Gorham-Stout disease (GSD) & lymphangiomatosis/generalized lymphatic anomaly (GLA).

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19919 Villa Lante Place
Boca Raton, FL 33434
Phone: (844) 588-5771 (toll free)

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Join LGDA Patient Matching Program

Patient Matching Registration Form

PLEASE TELL US ABOUT THE PATIENT

ABOUT THE PERSON COMPLETING THE FORM