INSPIRE Study Interest Form

INSPIRE (INcreased Sun Exposure without Pain In Research Participants with EPP or XLP)

United Porphyrias is supporting Mitsubishi Tanabe and the clinical study sites in referring patients with Erythropoietic Protoporphyria (EPP) or X-linked Protoporphyria for a Phase 3 clinical trial. This form will be used to help manage participant interest in the clinical trial. There is no obligation to participate by submitting this form. 

Please complete the following form and you will be contacted with detailed information and next steps to be referred to a study site.

Privacy is our #1 goal! Your responses will remain confidential and will not be shared without your consent. 

We look forward to connecting with you!
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First Name *
Last Name
Email Address
 *
Phone Number
 *
Street Address 1
Street Address 2
City
 *
State
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Zip Code
Country
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What type of Porphyria have you been diagnosed with? *
What is your age?
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Have you been been to a Porphyria Center for care or research before?
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If you have been to a Porphyria Center before, which center and what was the name of your doctor?

Yes, I agree to be contacted by the United Porphyrias Association regarding the above listed study.

Your information will never be shared without your consent per United Porphyrias Association Privacy Policy

We look forward to serving you!

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Yes, I would like to join the United Porphyrias Association to receive news, information and updates. UPA may also contact you for research opportunities related to porphyria and rare disease.

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