By submitting the following information, the affected individuals information will be sent to the North American Mitochondrial Disease Consortium (NAMDC) Patient Registry. You are also entitled to a free membership in the United Mitochondrial Disease Foundation.

For detailed information about NAMDC, click here.
To see a webinar with Dr. Salvatore DiMauro, the principal investigator for NAMDC, click here.

Membership in the UMDF is open to patients, parents, guardians, friends, relatives, medical professionals, allied health professionals, etc. You can Review the Benefits of UMDF Membership by clicking here!

Does THE PATIENT already have a UMDF/EFL LOGIN? click here to Auto Fill this form with their information.

PLEASE DO NOT USE YOUR LOGIN IF YOU ARE NOT THE PATIENT! CREATE A NEW LOGIN FOR THE PATIENT!!

* required information
Thank you for your interest in NAMDC and the UMDF! 
PATIENTS INFORMATION
(not person filling out the form unless you are the patient)
I understand this form must be filled out SEPARATELY for each person:* Yes, I Understand
I would like to enroll in the NAMDC Registry:* Yes
No
Title:
First Name:*
Last Name:*
Suffix/Degree:
Affected Individual:* Yes
No
Birth Date:*(mm/dd/yyyy)
Deceased:* Yes   No
Address Line 1:*
Address Line 2:
City:*
State:*
Province:
ZIP/Postal Code:
Country:*
Email:*
Phone:*
Create Username and Password
Username:*
Password:*
Verify password:*
Security Question:*
Security Answer:*
Please choose your included UMDF Membership Type or Opt-Out
FREE UMDF Hope Member
A Hope Membership - Does Not Expire
 
UMDF Energy Member - 1 Year
One Year Energy Membership
$50.00
UMDF Life Member - 2 Years
Two Year Energy Membership... You can choose your customizable Life Benefits from within the Members Section of the UMDF website by clicking on the link 'Life Benefits Selector' after registration.
$250.00
Opt-Out - NAMDC Registration Only
I wish to have my information shared with NAMDC but choose not to take advantage of becoming a UMDF Member.
 
In addition to any membership fees, Please accept an Additional Donation of:
(Optional)
Amount:$
CONTACT PERSONS INFORMATION
(person to be contacted concerning patient)
Relationship to Patient:*
Contact First Name:*
Contact Last Name:*
Contact Primary Phone:*
Contact Email Address:*


NAMDC Registration - The United Mitochondrial Disease Foundation - OLD