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New Patient Kit for Mito

View our New Patient Kit online, download it as a PDF, or request a paper copy of the using the form below.

Mito-New-Patient-Kit-Updated-3_10_23

Request a New Patient Kit (Mito)

"*" indicates required fields

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Ethnicity

Primary Language

Gender

Pronoun

Email*

Phone

What is your connection to mito?*

Patient

Parent

Spouse

Caregiver

Son

Daughter

Sibling

Grandparent

Grandchild

Aunt

Uncle

Cousin

Niece

Nephew

Friend

Teacher/Educator

Medical Professional

Physician

Nurse

Genetic Counselor

Social Worker

Researcher

Industry Rep

Other

Diagnosis Type

What is your diagnosis?*

Alpers’ Disease

ACAD9 Deficiency

Autosomal Dominante Optic Atrophy (ADOA)

Barth SyndromeA rare, genetic disorder of lipid metabolism that primarily affects males.

CACT Deficiency

CPEO

Complex I Deficiency

Complex II Deficiency

Complex III Deficiency

Complex IV Deficiency

Complex V Deficiency

CoQ10 Deficiency

CPT I Deficiency

CPT II Deficiency

Creatine Deficiency Syndrome

CUD/Primary Carnitine Deficiency

Friedreich’s AtaxiaFriedreichs Ataxia

GAII/MADD Deficiency

Kearns-Sayre Syndrome (KSS)

Lactic Acidosis

LCHAD Deficiency

Leigh Syndrome

Leukodystrophy

LHON

LHON Plus

Luft Disease

MCAD Deficiency

MCKAT Deficiency

MELAS

MEPAN

MERRF

MIRAS

MitochondrialRelated to the mitochondria. Cytophy

Mitochondrial DNA Depletion

Mitochondrial Encencephalopathy

Mitochondrial Myopathy

MNGIE

M/SCHAD Deficiency

Multiple Mitochondrial DysfunctionThis is when mitochondria do not work as well as they should due to another disease or condition. Many conditions can lead to secondary dysfunction. Syndrome

NARP

Pearson SyndromeA rare disease that targets the bone marrow and pancreas. Through dysfunction of cells in the bone marrow that produce white and red bloods cells along with platelets.

POLG Mutationsgenetic variant, genetic change

POLG 2

Primary Mitochondrial Myopathy

Pyruvate Carboxylase Deficiency

Pyruvate Dehydrogenase Deficiency

Pyruvate Dhydrogenase Complex Deficiency (PDCD)

SCAD Deficiency

Thymidine Kinase 2 Deficiency (TK2)

VLCAD Deficiency

Undiagnosed

Other

What is your child's diagnosis?*

Alpers’ Disease

ACAD9 Deficiency

Autosomal Dominante Optic Atrophy (ADOA)

Barth Syndrome

CACT Deficiency

CPEO

Complex I Deficiency

Complex II Deficiency

Complex III Deficiency

Complex IV Deficiency

Complex V Deficiency

CoQ10 Deficiency

CPT I Deficiency

CPT II Deficiency

Creatine Deficiency Syndrome

CUD/Primary Carnitine Deficiency

Friedreich’s AtaxiaImpaired coordination of voluntary muscle movements. Manifestations can include, among others, slurred speech, poor balance, unsteady walking, falling, and involuntary eye movements (nystagmus). Usual

GAII/MADD Deficiency

Kearns-Sayre Syndrome (KSS)

Lactic Acidosis

LCHAD Deficiency

Leigh Syndrome

Leukodystrophy

LHON

LHON Plus

Luft Disease

MCAD Deficiency

MCKAT Deficiency

MELAS

MEPAN

MERRF

MIRAS

Mitochondrial Cytophy

Mitochondrial DNA Depletion

Mitochondrial Encencephalopathy

Mitochondrial Myopathy

MNGIE

M/SCHAD Deficiency

Multiple Mitochondrial Dysfunction Syndrome

NARP

Pearson Syndrome

POLG Mutations

POLG 2

Primary Mitochondrial Myopathy

Pyruvate Carboxylase Deficiency

Pyruvate Dehydrogenase Deficiency

Pyruvate Dhydrogenase Complex Deficiency (PDCD)

SCAD Deficiency

Thymidine Kinase 2 Deficiency (TK2)

VLCAD Deficiency

Undiagnosed

Other

What is your loved one's diagnosis?*

Alpers’ Disease

ACAD9 Deficiency

Autosomal Dominante Optic Atrophy (ADOA)

Barth Syndrome

CACT Deficiency

CPEO

Complex I Deficiency

Complex II Deficiency

Complex III Deficiency

Complex IV Deficiency

Complex V Deficiency

CoQ10 Deficiency

CPT I Deficiency

CPT II Deficiency

Creatine Deficiency Syndrome

CUD/Primary Carnitine Deficiency

Friedreich’s Ataxia

GAII/MADD Deficiency

Kearns-Sayre Syndrome (KSS)

Lactic Acidosis

LCHAD Deficiency

Leigh Syndrome

Leukodystrophy

LHON

LHON Plus

Luft Disease

MCAD Deficiency

MCKAT Deficiency

MELAS

MEPAN

MERRF

MIRAS

Mitochondrial Cytophy

Mitochondrial DNA Depletion

Mitochondrial Encencephalopathy

Mitochondrial Myopathy

MNGIE

M/SCHAD Deficiency

Multiple Mitochondrial Dysfunction Syndrome

NARP

Pearson Syndrome

POLG Mutations

POLG 2

Primary Mitochondrial Myopathy

Pyruvate Carboxylase Deficiency

Pyruvate Dehydrogenase Deficiency

Pyruvate Dhydrogenase Complex Deficiency (PDCD)

SCAD Deficiency

Thymidine Kinase 2 Deficiency (TK2)

VLCAD Deficiency

Undiagnosed

Other

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