The code block below illustrates how one might use # and // as comments in your logic and calculations.

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Required format:

quaQXkePoRXNnWv4WEkXvwuUN46McKMEug7gVWydnmizIriZS4ChJS3cN9gYerfMQfB7WmKkXIhtRN7gwePceEqvEhGJzqIDb5qttT3uyFR6txpxn

UC Davis Neuromuscular Research Lab Registry

Please complete the form below if you are interested in participating in research or hearing about upcoming studies. Once you have completed this form you will be added to our Research Registry.

Your First Name:

* must provide value

Your Last Name:

* must provide value

Are you filling this out for yourself, or on behalf of someone else?

* must provide value

Myself

My Child

Other

Are you interested in being contacted about upcoming research studies that you or your child may qualify for?

* must provide value

Yes

reset

First Name

* must provide value

Last Name

* must provide value

Date of birth

* must provide value

Y-M-D

Gender

MRN

Has this individual been diagnosed with a neuromuscular disease?

Yes

reset

Type of neuromuscular disease

DMD

ALS

FSHD

SMA

CMT

Other

Other:

Would you like to add a second participant?

Yes

reset

First Name

Last Name

Date of birth

Y-M-D

Gender

MRN

Has this participant been diagnosed with a neuromuscular disease?

Yes

reset

Type of neuromuscular disease

DMD

ALS

FSHD

SMA

CMT

Other

Other:

Phone number

Second phone number

UC Davis Health takes protecting your or your child's information and privacy very seriously. Your or your child's information will not be released to research coordinators until you have initialed below. All information entered in the Research Volunteer Registry is sent to our servers via secure and encrypted means and is compliant with HIPAA standards. To learn more about UC Davis Health System's policies and compliance programs visit:

http://www.ucdmc.ucdavis.edu/compliance/guidance/privacy/

* must provide value

How did you hear about our research registry?

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