Childhood Stroke Project

Participant Details

First Name

Last Name

Personal Email

Phone

I am a:

The stroke occurred:

Age at stroke:

State

How did you find out about the project?

Your age group:

I consent to being contacted via email to receive project updates and invitations to take part in the project

I am under 18 years old

You are under 18 years old, we need to make sure your parent/guardian agrees to you taking part in the Childhood Stroke Project.

Parent/guardian's Name

Parent/guardian's phone number

Parent/guardian's email

I have discussed taking part in the Childhood Stroke Project with my parent/guardian

Hidden Use Only

	True
Bypass Validation Rules (Patient Contact)
Bypass Validation Rules (GP Contact)
Bypass Validation Rules (Carer/Next of Kin Contact)
Form Auto-Assign (Case)
Health Record (Contact)

Business Hours (Case)

Record Type ID (Case)

Child Stroke Queue ID

Case Type (Case)

Case Origin (Case)

Subject (Case)

Body

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