MAST2CARE Apply Now - Global Allergy and Asthma Excellence Network

Center Information

Clinic Name

Center Name / Department Name *

Center Address

Street Address *

Address Line 2

City *

State / Province / Region

ZIP / Postal Code *

Continent

Country *

Center Contact Data

Center Email *

Center Phone

Center Website

Please note: Some of the information listed above (including the center’s name and address, contact information for patients, website and logo) may be published on the website of Global Allergy And Asthma Excellence Network.

Department Information

Department Email

Department Phone

Department Mail Address

MAST²CARE Department Head

Department Head Title

Department Head Name *

Department Head Email

MAST²CARE Department Deputy

Department Deputy Title

Department Deputy Name

Department Deputy Email

Application

Dear Dr. Siebenhaar,

I wish to join the MAST²CARE network and hereby apply for our center to become a MAST²CARE center.

Explanation *

I have read the 32 requirements and confirm that our center fulfils the requirements and deliverables.

Please fill in the Power Point document “Center Presentation for Audit_PP template“, save it as a pdf file and upload it here. This presentation is mandatory for the application process and basis for the audit.

Download the presentation template here

Upload Center Presentation document*: Accepted file types: pdf, Max. file size: 25 MB.

Verify Information

Please review and verify your information before submitting your application. If you need to change your submitted information, click "Previous" at the bottom of this page to go back.

Center Information

Center Name:

Center Address:

Center Contact Data:

Department Data:

Application

Please explain why you want to become an Mastocytosis Center of Reference and Excellence:

Consent: I have read the "32 MAST²CARE requirements and deliverables" and confirm that our center fulfils the requirements and deliverables.

I have uploaded the document “Center Presentation for Audit_PP template“, which is mandatory for the application process and basis for the audit: Yes

My center is already a member of the following Global Allergy and Asthma Excellence networks:

Applicant information

Applicant First Name *

Applicant Last Name *

Applicant Email *

Mailing Preferences

I agree to receive Global Allergy and Asthma Excellence network-related information, updates, and relevant announcements. I understand that I can withdraw my consent at any time and confirm that I have read the privacy policy.

I would like to receive updates about:

General Updates of Global Allergy and Asthma Excellence Network Angioedema (ACARE) Atopic Dermatitis (ADCARE) Anaphylaxis (ANACARE) Asthma and Allergic Rhinitis (AIRWAYSCARE) Mastocytosis (MAST²CARE) Urticaria (UCARE)

Signature

Application Date *

Please enter the result*:

5 + 6 =

Applicant Signature*:

Please make sure you have signed and entered the result of the calculation before submitting.

MAST²CARE Application form

Center Information

Center Address

Center Contact Data

Department Information

MAST²CARE Department Head

MAST²CARE Department Deputy

Application

Verify Information

Center Information

Application

Applicant information

Mailing Preferences

Signature