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Cholesterol
Inherited High Cholesterol
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Register with MEDPED
 
 
General Information: Register with MEDPED
 
 
Register with MEDPED

You can register with MEDPED using this form. Alternatively you can contact MEDPED to register via other methods or find out more information.

Online Patient Registration Form
Title: (Mr., Mrs., etc)
Surname:
Given Name(s)
Date of Birth (dd/mm/yyyy)
Street:
City:
State:
Post Code:
Phone (daytime):
Email:
About You:
If you have had a cholesterol test, what was your level without drug treatment?

Do you have a history of:
Condition
(Tick for Yes)
At What Age?
heart attack
angina
bypass surgery
angioplasty/stent

About Your Family:
Do any of your family have a history of:
Condition
(Tick for Yes)
At What Age?
high cholesterol
previous coronary heart disease
heart attack
angina
bypass surgery
angioplasty/stent
sudden death

Please press the Submit button to send your completed form to MED-PED, or press the Reset button to clear all fields.

 
 
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