CHM Registry Signup
This form takes less than 5 minutes to complete.
Consent or Parental/Legal Guardian Permission and Child/Dependent Assent
I, the person filling out this form, acknowledge that I give or have full consent of the person who has CHM, for whom this form is being filled out. I understand that all of the information provided will be treated as confidential and that under no circumstance will personal information such as name, address, phone numbers, email, etc., will be shared with any other source, or third party. Only non-personalized data will be shared.
I have read and understand the terms and conditions and I/we agree to participate in the Registry as described above.
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This form was created inside of Choroideremia Research Foundation.
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