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Help Us Serve You Better
Help Us Serve You Better
Please fill out the form below to help us better serve and engage with you on your journey with amyloidosis.
Title / Prefix
Optional
First Name
Middle Name
Optional
Last Name
Suffix (e.g., Jr., Sr., III)
If Applicable
Spouse or Domestic Partner's First and Last Name
(this helps us combine households in our database)
Personal Email
Work Email
I am a...
Patient
Potential Patient
Caregiver
Patient Family/Friend
Loved One of Patient Who Passed
Nurse
Clinician
Scientist
Pharma Representative
Government
Other
If other, please describe:
Amyloidosis Type
Please select...
AA
AL Amyloidosis
AB2M
ALect2
Hereditary ATTR
Hereditary Non-TTR
Hereditary Untyped
Localized
Wild-Type ATTR
Untyped
Other
Amyloidosis Type (if known)
Please select...
AA
AL Amyloidosis
AB2M
ALect2
Hereditary ATTR
Hereditary Non-TTR
Hereditary Untyped
Localized
Wild-Type ATTR
Untyped
Other
If other type, please explain:
What genetic variant do you have?
Please select...
Glu54Gly
Ile68Leu
Ile84Ser
Phe64Leu
Ser77Tyr
Thr60Ala
Val122Ile
Val30Met
APOA1
Gelsolin
Other
Unsure
There are many known variants - some of the more common ones are listed here. Please select "other" if you don't find yours among this list.
Other genetic variant, if known:
Should be in the format "Abc12Abc" or "Abc123Abc", ex: Val30Met
Gelsolin Type, if known:
Should be in the format "Abc12Abc" or "Abc123Abc", ex:
Asp187Asn
APOA1
Type, if known:
Should be in the format "Abc12Abc" or "Abc123Abc", ex:
Glu34Lys
Year of Diagnosis
Would you mind sharing the name of your loved one?
Organization
Professional Title
Academic Credentials
Ex: MD, PhD
Specialty
Please select...
AL Amyloidosis
ATTR Amyloidosis
Cardiology
Gastroenterology
Hematology
Immunology
Nephrology
Oncology
Pulmonology
Radiology
Rheumatology
Other
If other specialty, please explain:
Are you active in research?
Yes
No
About how many AL patients do you see monthly?
Please enter 0 if none.
About how many ATTR patients do you see monthly?
Please enter 0 if none.
I would like an ARC team member to contact me:
Yes, I need information, resources, or support and would like to be contacted by the Clinical Care and Education Manager
Yes, I'd like a member of the development team to contact me regarding donating or adding ARC to my will
No, I do not have a request at this time
I'd like to participate in the following as they become available:
ARC Surveys
ARC Surveys and studies are conducted throughout the year with the goal of understanding the experiences of patients and caregivers. The purpose of the surveys can vary from gaining perspectives on the journey to diagnosis to clinical experiences, evaluating the benefit versus risk that patients are willing to take with treatments, and other insights.
Focus Groups & Patient Panels
Focus Groups & Patient Panels can provide you with a unique opportunity to give input into shaping research. These forums may review planned research or assess the value of different types of treatments through the eyes of patients. This provides important insights and can lead to improvements in the research that is being done.
Advocacy
Advocacy is a critical function of our work to improve and extend the lives of those with amyloidosis, and we need your help. We’d love to connect with you if you’re a patient or caregiver willing to be a subject of one of our patient story videos, speak at the Amyloidosis Forum or other amyloidosis events, or help raise awareness about these devastating diseases.
Other Research Opportunities
Are any of the following symptoms present:
Nerve symptoms (neuropathy)
Cardiac symptoms (cardiomyopathy)
Renal (kidney) symptoms
Gastrointestinal (GI) symptoms
Please provide any additional information you feel might be helpful for us to know regarding advocacy or research participation.
(If applicable: treatments received, resources that have been helpful to you, clinical trial experience or interest level, etc.)
Please list any non-English languages you speak
contactme
constituentID
Address details help us build future programs to better fit our community. Your information will not be shared.
Address Type
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Home
Work
Address Line 1
Address Line 2
City/Town
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Postal Code
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undeliverable billing address
Phone number
Providing demographic information helps ARC when applying for certain grants and will not be shared.
Gender
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(In mm/dd/yyyy format, please.)
Birth Year
Race/Ethnicity
(select all that apply)
American Indian or Alaska Native
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Other
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If there is anything else you'd like us to know, please leave a note here.
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Patient
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ARC Supporter