Registry Access Form
To add or remove a team member from your PERForm Registry Database, please complete the following information.  To protect these data, please notify the Coordinating Center when a user is no longer employed at your hospital.
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Email *
Please Provide Institution Name
 *
Please Provide Submitter's Name and Title/Role with PERForm *
Effective Date of Registry Access Additions or Updates
MM
/
DD
/
YYYY
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