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Your Name (required) first name and surname

Your Email (required)

Confirm Your Email (required)

Do you have BEB (required)

How long have you had BEB (required)

How long did it take from symptoms to diagnosis (required)

Treating Doctor

Current Treatment

If "Other", what sort of treatment are you having?

Location - Country (required)

Location - State (required)


It would be very useful if you would add your phone number as there are sometimes occasions where it would be helpful to have quick contact for administrative purposes. It would never be shared with other members.

Home Phone


Contact (required) - Would you like to be notified of fellow members in your State? This will enable you to contact them and for them to contact you. Only your name and email address will be forwarded.

Further Information you may like to tell us

Please select the box in the reCAPTCHA below to let us know you are a real person.

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