Survey - Decode Duchenne: Online Application Form - Parent Project Muscular Dystrophy

This form is intended for use by healthcare providers. If you are a patient or a family member and would like to request testing, please contact us.

PLEASE NOTE: This application is ONLY for female carrier testing. An application is no longer required for diagnostic testing. Go directly to the PerkinElmer website to order diagnostic testing.

PARTICIPANT(PATIENT) INFORMATION

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Question - Required - Patient Name

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Question - Required - Date of Birth

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Question - Required - Sex at Birth

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Question - Required - Patient Address

(Maximum response 255 chars, approx. 5 rows of text)

PROVIDER INFORMATION

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Question - Required - Name

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Question - Required - Clinical title

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Question - Required - Institution

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Question - Required - Street Address

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Question - Required - City

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Question - Required - State

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Question - Required - Zip Code

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Question - Required - Fax Number

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Question - Required - Phone

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Question - Required - Email (Note: Paperwork for testing, including requisition and specimen kit ordering instructions, will be sent to this email following approval of application.)

Specimen Collection Kits

The following types of kits are available from PerkinElmer Genomics:

Blood
Dried Blood Spot (DBS) cards
Saliva

Saliva kits can be shipped directly to a patient's home, but the ordering provider must request the kit directly on the PerkinElmer website and must first upload the completed requisition. Directions for ordering kits will be sent via email to the address above with the requisition attached.

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Question - Required - Is this patient currently in clinic or coming into clinic today? (If yes, we will send the requisition today, assuming we receive application between 8-5 ET M-F.)

Please confirm that this participant:

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Question - Required - I attest that my patient:

Is a citizen or resident of the United States or Canada

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Question - Required - I attest that my patient:

	Is an asymptomatic individual of an affected relative with a known causative DMD variant, OR
	Is an asymptomatic individual of an affected relative with NO known causative DMD variant

Question - Not Required - Since carrier testing is being requested, please enter information regarding patient's affected relative including: Name, relationship to patient, date of testing, and DMD variant identified

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Question - Required - Have you used Decode Duchenne in the past?

Question - Not Required - Others questions or comments:

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Question - Required - I attest that I am a healthcare provider (physician/nurse/genetic counselor) directly involved in the evaluation and treatment of this patient. I attest that the information provided on this application is true, accurate and complete to the best of my knowledge and I understand that I am liable for any falsification or omission of information.

De-identified data from the Decode Duchenne program may be shared with industry sponsors, including Sarepta, PTC Therapeutics, Vertex, and NS Pharma. This de-identified data may be used for diagnostic and therapeutic disease research, such as understanding the incidence of certain dystrophin gene variants, evaluating and improving the diagnosis of Duchenne/Becker, and developing novel variant-specific therapeutic strategies.