ARC Participant Contact Information Form
Your participation matters. Contact us to let us know you're interested in helping us further our research efforts. It's easy to get involved and we're here to help guide you through the process. Thank you for your interest in helping us take a step closer to finding a cure for amyloidosis.
We are doing the research that matters - and we need your help.
Country of residence
State (if living in the US)
New Hampshire (NH)
New Jersey (NJ)
New Mexico (NM)
New York (NY)
North Carolina (NC)
North Dakota (ND)
Rhode Island (RI)
South Carolina (SC)
South Dakota (SD)
West Virginia (WV)
What best describes your relationship to Amyloidosis
Patient (I have amyloidosis)
Caregiver (I provide care to someone with amyloidosis)
Type of amyloidosis (if applicable)
If you have hereditary ATTR, what genetic variant do you have?
N/A I do not have hereditary ATTR
Do you have any of the following symptoms? (Select all that apply)
Nerve symptoms (neuropathy)
Cardiac symptoms (cardiomyopathy)
What are you most interested in getting involved with? (Select all that apply)
Patient Panel Discussion
Advocacy of ARC's Mission
Please provide any additional information you feel might be helpful for us to know (If applicable: type of amyloidosis, year diagnosed, treatments received, resources that have been helpful to you, clinical trial experience or interest level, etc.)
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