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Thank you for taking the time to complete this information.

The Lily Foundation puts those affected by mitochondrial disease at the heart of everything we do.

We exist to support patients, advocate for those affected by mito and provide a platform for your voice to be heard.

If you would like to learn more about mitochondrial disease, how we can support you and how you can get involved, please visit the Patients and Professionals section of our website.

A patient (aged 18+) affected by Mitochondrial Disease

A parent or carer of a child (aged < 18 years) affected by Mitochondrial Disease

An advocate of an adult (aged18+) affected by Mitochondrial Disease

A parent of a child (aged <18 years) who has passed away due to Mitochondrial Disease

A Parent of a loved one who has passed away due to Mitochondrial Disease (aged 18+)

Date of Birth of the person affected by Mitochondrial Disease:

Date of Death of the person affected by Mitochondrial Disease (if applicable):

Ethnicity: Please Select English, Welsh, Scottish, Northern Irish or British Irish Gypsy or Irish Traveller Any other White background White and Black Caribbean White and Black African White and Asian Any other Mixed or Multiple ethnic background Indian Pakistani Bangladeshi Chinese Any other Asian background African Caribbean Any other Black, African or Caribbean background Arab Any other ethnic group

First language: Please Select English French German Italian Polish Portuguese Romanian Russian Spanish Turkish Arabic Bengali Chinese Gujarati Persian/Farsi Punjabi Somali Tamil Tagalog/Filipino Urdu

Has a diagnosis of mitochondrial disease been given to you by a medical professional? (Y/N): --------- Yes No (still undergoing testing)

If yes, when did you receive the diagnosis (MM/YY)? :

Are you a patient of any of the following specialist hospitals: London UCL Newcastle Oxford Cambridge None of These