International Porphyria Support Group

Patient Referral Form

Patients with possible porphyria must be referred by a clinician who is familiar with their care.

About the referring clinician:

Clinical title

Clinician Name(Required)

First Last

Clinician hospital/office

Clinician postal address

Clinician email address(Required)

Clinician telephone number

Languages spoken

Date of referral(Required)

About the patient:

Patient initials(Required)

Please do not provide full name

Patient date of birth(Required)

Patient gender

Patient nationality

Patient City/Town(Required)

Patient Country(Required)

Reason for referral:(Required)

Please provide a summary of patient’s medical history including the reasons for suspecting porphyria, and the results of any tests that have been carried out

An international network of experts working together to improve healthcare services for porphyria patients

International Porphyria Network

Postal adress

c/o studio12 gmbh
Kaiser-Josef-Straße 9
6020 Innsbruck, Austria

Email: office@ipnet.org
Phone: +43 512 89043 600

Registered adress

NAPOS, Department of Medical Biochemistry and Pharmacology (MBF)
Haukeland Universitetssykehus, P.O. Box 1400
5021 Bergen, Norway

Email: office@ipnet.org
Phone: +43 512 89043 600

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