Decode Duchenne: Online Application Form

 

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: If you are applying for carrier testing of an asymptomatic female, we are currently taking applications for our January 2020 waiting list, as current slots have been filled. This applies to our carrier testing program only.

 

PARTICIPANT(PATIENT) INFORMATION

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

 

PROVIDER INFORMATION

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Would you like specimen shipping kits sent to your office? (PerkinElmer lab kit(s) will be shipped to address above.) If yes, please provide the following information:

   


   


   


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Please confirm that this participant:

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Question - Required - I attest that my patient:

 

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Question - Required - I attest that my patient:

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Question - Not Required - If no, how did you hear about the program?

 

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

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