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Emma Kinderziekenhuis AMC Amsterdam

RbNeuroQoL

RbNeuroQoL (t/m 15 jaar)

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Department	Retinoblastoom EKZ
Hospital	Emma Kinderziekenhuis AMC Amsterdam
Your study specific code
Your account	What is your relation to the child? Mother Father Guardian (male) Guardian (female) Grandmother Grandfather What is your birthdate? dd-mm-yyyy Your e-mail address: Is there someone else taking care of the child? Yes No What is his/her relation to the child? Mother Father Guardian (male) Guardian (female) Grandmother Grandfather What is his/her birthdate? dd-mm-yyyy If you want to create a separate account (with a separate password) for this person please fill in his/her e-mail address. When this field is left blank you will share a single account.
Child's e-mail address	If your child is 8 years or older and has their own email address, please enter this email address here. A personal account will then be created for your child, so that you and your child can log in with your own email address and password. You can leave this field blank if your child does not have their own email address or if you don’t want to create a separate account for your child.
Date of birth of the child	dd-mm-yyyy
Gender	Boy Girl Other
Terms	I agree with the terms and conditions of KLIK
Patient number	Please fill in your child's patient number at the hospital. If you don't know this number you can leave it blank.