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Required format:

ZyiGgRBZt4hEBB2bkjk779P5dDMSBqqCMWwDPn9Z3vMeK2o3vAL5XV9GBfFf66fY

If you are interested, please provide the following information to confirm eligibility for the Vascular Ehlers-Danlos Syndrome (vEDS) Research Collaborative Study.

This is a natural history study. The purpose of the vEDS research collaborative study is to consent patients and obtain medical records and radiologic imaging to support a natural history study where the course of vEDS can be followed. This is very important as it will help us learn more about the natural history of vEDS and guide future care and treatment options.

If you choose to participate in this study, we would collect your medical history, genetic testing results, and your future medical treatment and outcomes by reviewing your medical records and imaging studies.

For more information visit our website
Follow us: vEDs Collaborative Facebook | vEDs Collaborative Twitter | Sherene Shalhub Twitter

First Name

* must provide value

Last Name

* must provide value

Full Name

Phone Number

* must provide value

E-mail

* must provide value

Address

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Are you over 18 years old?
(We are enrolling all ages, including children)

* must provide value

Yes

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Please upload your molecular confirmation of the vEDS diagnosis (genetic testing results or skin biopsy results)

for assistance contact vedscoll@uw.edu

* must provide value

Upload file

Do you have more confirmation documents to upload?

Yes

reset

Additional confirmation documentation
(as needed)

Upload file

Additional confirmation documentation
(as needed)

Upload file

Additional confirmation documentation
(as needed)

Upload file

Other comments (regarding confirmation only):

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Secondary contact's first name

Secondary contact's last name

Relation to you

Secondary contact's phone number

Secondary contact's email

Molecular genetic confirmation confirmed for which of the following:

self

father

mother

son

daughter

other

Describe other types of confirmation:

Other medical information

Upload file

Consent Form

Upload file

HIPAA Form

Upload file

Gene mutation:

Protein change:

Type of mutation:

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