Informed Consent / Account Creation

Create Professional Account

Please complete the form below to request professional access to the Registry. Once approved, you will have access to graphs and charts representing all Registry members.

First Name:
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Last Name:
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Email:
* This Field is required Information for: Email : Please enter a valid e-mail address. A confirmation email will be sent to this address upon registration. * This Field is required Information for: Verify Email : Please enter a valid e-mail address. A confirmation email will be sent to this address upon registration.
Username:
* This Field is required Information for: Username : Please enter a valid username.  No spaces, at least 3 characters and contain 0-9,a-z,A-Z
Password:
* This Field is required Information for: Password : Please enter a valid password.  No spaces, at least 6 characters and contain lower and upper-case letters, numbers and special signs * This Field is required Information for: Verify Password : Please enter a valid password.  No spaces, at least 6 characters and contain lower and upper-case letters, numbers and special signs
Organization:
Organization Type:
Title/Occupation:
Address:
* This Field is required
Address 2:
Address 3:
City:
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State:
Zipcode:
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Country:
* This Field is required
Phone:
* This Field is required Information for: Primary Phone  : <p>
	(xxx-xxx-xxxx)</p>
Degrees:
Access Purpose:

Any use of Registry data for research purposes and publication must cite the Myotonic Dystrophy Family Registry as its source.

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I agree to the terms and conditions.

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