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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. 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.
You will receive a confirmation email after submission of the registration form from "monogenicdiabetes@uchicago.edu". Please add this email address to your list of known contacts to avoid the email being flagged as "junk". If you do not receive the confirmation email within 24 hours after submission please check your junk/spam folders.
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
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Exactly how old was the patient when FIRST diagnosed with diabetes (or blood sugar
problem)?
For example '3 months old’ or '36 years old'.”
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Age at diagnosis of diabetes
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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.
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E-mail Address
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Please enter only a 10-digit phone number, without a 1 at the beginning, for example:
773-702-0829, 7737020829 or (773) 702-0829
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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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Please enter only a 10-digit phone number, without a 1 at the beginning, for example:
773-702-0829, 7737020829 or (773) 702-0829
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Phone
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Email
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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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