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Phase 2/3 Clinical Study to evaluate PTX-022 in PC

If you are interested in participating in the Phase 2/3 Clinical Trial, please fill out the information below:

Contact Information *This question is required.

First Name
Last Name
Address
City
State
Zip/Postal Code
Phone Number
Email address

What is your affected gene? *This question is required.

Have you been in a clinical trial in the past 60 days? *This question is required.

Are you willing to travel? *This question is required.

Are you willing to have home health visits? *This question is required.

I authorize
Int'l Pachyonychia Congenita Research Registry (IPCRR)
c/o PC Project
PO Box 17850
Holladay, UT 84117 USA
Ref: WIRB #20040468/1057496

to release my name, phone number, email address and PC gene to the appropriate Phase 2/3 study doctor and coordinator *This question is required.

(enter your initials in box)

Signature *This question is required.

Clear

Signature of

Date *This question is required. This question requires a valid date format of MM/DD/YYYY.

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