STARGARDT DISEASE REGISTRY

Register your name if you would like us to contact you, and to receive updates about our Stargardt disease development program.

If you have Stargardt disease or know someone who has Stargardt, and if you would like us to contact you about our clinical trials, please input your name and fill out as much information as you can.

No identifiable information (such as name, email or phone number) will be disclosed to any 3rd party. We will use your information to contact you or your physician about upcoming trials.

At what age did you start having visual trouble ?

 
Back then, what was the vision of your best seeing eye (20/xxx)?
If you do not know the numbers, use your own words to describe your vision ("good", "bad", "ok", what you could or couldn't see)
What is your vision today (best seeing eye, 20/xxx)?

First Name
 
Last Name
 
Zip Code
 
Country
 
City
 
How old are you today?
 
Telephone
 
Email
 
Have you been genetically confirmed for Stargardt (Yes/No)?

 
If yes, please provide the detected ABCA4 genetic mutation(s)

 
Name of your ophthalmologist

 
Contact information of your ophthalmologist (phone, email or both)

 
If you are under 18 years old, please enter the name of a parent or legal representative:
 
If you filled out this form for someone else, please enter your name here
 

Alkeus Pharma takes your personal information very seriously. The information you provide will only be used by Alkeus Pharma to send you additional questions, provide updates on clinical studies, or send other helpful news on Stargardt disease trials and research.

If you would like to be removed from our database, please email us at info@alkeuspharma.com

Please share this website with people you know who may have an interest in Stargardt disease.

By submitting this form you agree to the terms:

  • There is no guarantee you will be enrolled in any clinical trial
  • You authorize Alkeus Pharma and parties acting on its behalf to contact you
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