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After looking at the information about our studies, if you think you qualify and
would like to participate, then you should complete the form below. This information
will allow us to contact you to clarify your eligibility and guide you through an
informed consent process regarding our research.
Please enter as much information as you can and note that you must include at least
one phone number or email address through which we will be able to reach you (if you do not have an email address, please call our research team at (773) 702-0829 to register). ALL
information is strictly confidential and will not be used for any other purpose
than this research study. Your personal information will ONLY be used to contact
you regarding aspects of this research, and will NOT be shared with any other parties.
This is a SECURE page.
NOTE: If you are a physician/diabetes provider of a patient that you feel may qualify,
please direct your patient to this website. DO NOT enter any information about your
patient.
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*Your relationship to patient
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* Specify Other Relationship
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Exactly how old was the patient when FIRST diagnosed with diabetes (or blood sugar
problem)?
Please enter numerical value only and select the appropriate units
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Age at diagnosis of diabetes
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Please select units
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Why do you think the patient might have a monogenic form of diabetes?
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Check all that apply:
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* Your First Name
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*Your Last Name
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Contact Information
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Please enter at least one phone number or email address at which we will be able
to reach you. If you don’t have an email address, please call the research team at (773) 702-0829 to register.
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E-mail Address
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Home Phone
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Mobile Phone
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Work/Other Phone
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Address
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Address 2
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City
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State
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Please enter 5 or 9-digit zip / postal code.
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Zip / Postal Code
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Country
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If you live outside the 50 United States, then please provide complete address information
or clarifications in the comments box below.
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Physician or Provider
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Please enter information about the doctor or clinician provider currently primarily
responsible for the management of the patient’s diabetes.
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Name
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Address
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Address 2
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City
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State
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Please enter 5- or 9-digit zip / postal code.
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Country
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Phone
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Email
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Fax
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How did you hear about our research studies?
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Check all that apply:
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Please provide any details such as which news report you read, which web site mentioned
or linked to our studies or which other way you found out about us
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Comments or Questions
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Please use this space for any clarifications or questions you may have. If the patient
is a ward of the state, please give the name and contact information for the person
and agency responsible for providing legal consent for any medical procedures or
research.
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