300 Longwood Avenue
Boston, MA 02115
(617) 355-6000
Clinical Services (Celiac Disease Program and Support Group):
Celiac Patient Education Information: Support Group Registration Form Instructions
Due to federal privacy regulations (HIPPA), we have had to revise the form to make sure you understand and consent to participate in each of our activities.
Checking the first box allows us to send you our quarterly newsletter.
Checking the second box allows us to send additional information such as gluten-free food lists and party announcements. If you provide us with an e-mail address and permission to contact you by this method, we may occasionally send electronic announcements of a time-sensitive nature.
Checking the third box allows us to share information regarding new members with members of our outreach committee. This committee's activities are described in the president's letter.
NOTE: This box also requires a signature. Checking the fourth box allows our group to share information ONLY with other members of the support group. We MUST have your signature to do this. This allows us to help families network with one another within the whole membership or based on specific similarities among the membership (i.e. age of child, hometown, presence of additional disease, etc.) For this reason, we ask that you consider sharing your child's information with the group.
Due to federal privacy regulations (HIPPA), we have had to revise the form to make sure you understand and consent to participate in each of our activities.