User account

Account information

Username: *

Spaces are allowed; punctuation is not allowed except for periods, hyphens, and underscores.

E-mail address: *

A valid e-mail address. All e-mails from the system will be sent to this address. The e-mail address is not made public and will only be used if you wish to receive a new password or wish to receive certain news or notifications by e-mail.

Contact Information

Gender: * MaleFemale

First Name: *

Last Name: *

Address: *

City: *

State: *

Country: *

Postal Code: *

Phone:

Alternate Phone :

E-Mail Listservs

As a registered member of PXE International, you are automatically subscribed to our PXE Announcements listserv when you provide: --I'd like to subscribe to the PXE Medical List.I'd like to subscribe to the PXE Chat List.

MemberGram Newsletter

As a registered member of PXE International, I'd like to receive the MemberGram newsletter via (choose one):: --E-mail (PDF Format)Audio Format (for the "hard of seeing")Print (through the mail)Don't Send the MemberGram. I will read it or print it from the PXE web site.

In an effort to be good stewards of your financial support, we appreciate it if you are able to receive the MemberGram electronically via e-mail or print it from our web site. This will help reduce printing and mailing costs. Thank you.

PXE Information

Check all that apply: --I have PXE.I have a relative with PXE.I have a friend with PXE.

I would like: (check as many as you wish): --to participate in the clinical questionnaire (What is this?)written informatione-mail support (please complete e-mail field)a pen pal (I don't have e-mail)telephone palI have a question

I have a question about:

You may share my name with other people who have PXE and are looking for someone in my area: --YesNo

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