Short QT Syndrome

Submit Story

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Would you like your Short QT story published on this site.  We would like to collect and post as many patient stories as we can.  We hope providing these stories will help other families who suffer from Short QT Syndrome.  As of November 2004, less than 50 individuals had been identified as having SQTS, so please help us by submitting your story.

Submit your story by filling out the form below.  We will include as much or as little information as you like on the website. 

We would like to contact you to make certain the information is valid and correct.  We will also inform you when your story has been published so you can check the story and report any needed corrections.

We appreciate your help,

Jack Collier, MD  

 

Patient Information:

            Name 
   	     Age 
             Sex Male Female

 

Contact Information:

  Street Address 
 Address (cont.) 
            City 
  State/Province 
 Zip/Postal Code 
         Country 
      Home Phone 
          E-mail 

 

Select any of the following options that apply:

Include my first name on the web page
Include my whole name on the web page
Include my age on the web page
I would like to submit a picture for the web page

My story:


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