Blue Nevus Melanoma Patient Registry ("Patient Registry")

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The purpose of this form is to learn about your blue nevus melanoma profile and to help us or our authorized third party research partners determine your potential eligibility for current and/or future clinical trials. If you meet preliminary eligibility for current and/or future clinical trials, we and/or our research partners may contact you to inform you of these trials. We and/or our research partners may also contact you via the contact information you provided to clarify certain information you provided, collect further information about you, or follow up with you if your Patient Registry application is incomplete. We may also use the information provided to us for other lawful business purposes as permitted under applicable laws, such as inviting you to join our community events. Additionally, we may use the information you provide for research purposes and for potential product development.

The Blue Nevus Melanoma Foundation will attempt to keep your personal identification information such as name, address and phone number confidential. However, you understand that there is always a potential risk of loss of confidentiality of the information you provide while taking part in this Patient Registry. As a small organization, Blue Nevus Melanoma Foundation relies on Google Enterprise, Gmail, and Google Storage for managing and protecting its information.

Please provide your email below: *

Relationship to patient

I am the patient.

I am the parent/legal guardian/caregiver of the patient.

I am related by blood to at least 2 patients who have a rare disease but I do not have the rare disease.

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