SMA Masterclass Intake Form

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* 1. Name:

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* 2. Email:

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* 3. Primary medical group or hospital affiliation:

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* 4. City/Town:

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* 5. Province:

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* 6. Please indicate your specialty or medical discipline

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* 7. How familiar are you with MDC?

Not familiar

Somewhat familiar

Very familiar

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 8. Have you previously seen/treated patients with Spinal Muscular Atrophy in the past?

Yes

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* 9. How many patients with Spinal Muscular Atrophy do you currently have?

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* 10. Please rate your knowledge of Spinal Muscular Atrophy today:

Not knowledgeable

Somewhat knowledgeable

Expert

Clear

i We adjusted the number you entered based on the slider’s scale.

SMA Masterclass Intake Form

Question Title

* 1. Name:

Question Title

* 2. Email:

Question Title

* 3. Primary medical group or hospital affiliation:

Question Title

* 4. City/Town:

Question Title

* 5. Province:

Question Title

* 6. Please indicate your specialty or medical discipline

Question Title

* 7. How familiar are you with MDC?

Question Title

* 8. Have you previously seen/treated patients with Spinal Muscular Atrophy in the past?

Question Title

* 9. How many patients with Spinal Muscular Atrophy do you currently have?

Question Title

* 10. Please rate your knowledge of Spinal Muscular Atrophy today:

Question Title

* 11. How did you hear about this masterclass?