Help us to help you - Tuberous Sclerosis Australia

Thank you for providing us with more information about you so we can best help you.

In order for us to get to know you a little better and be able to tailor our services to your needs, we invite you to take a moment to please provide us with a few details about you and your family. Please complete the below brief form. Any information you provide to us will be kept private and confidential – we do not share your personal information with any other organisations or charities.

You can also call us on 1300 733 435 to tell us a little more about you and your family.

Additional information about you

Please provide your contact details here

Name*
First Last
Email*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
What is your year of birth?
What is your personal connection to TSC?*
If you have TSC, are you able to live independently?
With respect to any family members or people you care for who have TSC. What is the name of the person with TSC?
First Last
What is the year of birth of your family member with TSC?
What is the gender of the person with TSC?
What is your relationship to them?
Are you a carer for this person?
Do you have any other family members who have TSC?
We welcome any additional comments or feedback you may have

Thank you for taking the time to provide us with more information about you.