Toggle navigation Load unfinished survey Resume later Exit and clear survey Language: English English Français default Caution: JavaScript execution is disabled in your browser or for this website. You may not be able to answer all questions in this survey. Please, verify your browser parameters. LHON Canada Membership Registration Membership in LHON Canada is free. We keep track of events in LHON community world wide and pass the information on to you via email. To help us better serve your needs, please fill in the membership form below. Thank you! Contact Information (This question is mandatory) Name (This question is mandatory) City/Town (This question is mandatory) Province/State (This question is mandatory) Country (This question is mandatory) Email Address General Information (This question is mandatory) What is your preferred language? English French (This question is mandatory) I am a __________? Check all that apply Person affected with LHON sight loss and/or other symptoms Carrier of LHON mutation (no symptoms) Parent or Legal guardian of affected individual Spouse, Relative or Friend of Affected Individual(s) Medical Professional Medical Supplier Other: To help LHON Canada better meet your needs, which of the following types of information would you be interested in receiving by email? Check all that apply Research initiatives & developments Clinical trials Treatments and/or therapies Volunteer opportunities Fundraising events Connecting with others Assistive technology Advocacy initiatives Other: What is your Birth Year (enter 4 digits) Only numbers may be entered in this field. (This question is mandatory) I agree to be added to the LHON Canada Electronic Mailing List. You may unsubscribe at any time. Oui Non Affected / Carrier Information **The following 5 questions are ONLY for those who are Affected OR are Carriers** What sex were you assigned at birth on your orginal birth certificate? Choose one of the following answers Male Female Intersex In what year did your symptoms, if any start? (enter 4 digits) Only numbers may be entered in this field. Please specify your LHON mutation Check all that apply G11778A T14484C G3460A Plus I'm unsure Other: How many others in your extended family that you are aware of have or have had LHON symptoms? Only numbers may be entered in this field. Submit Load unfinished survey Resume later Please confirm you want to clear your response? Exit and clear survey ×
