TPRI Registry

TPRI Registration Form
Consent for Use/Disclosure of Protected Health Information (PHI)

Your responses to the study questionnaire are confidential and will be protected to the best of our ability. Your name or any other identifying information will not be used in reports or publications resulting from this study. We will stop using your information at the conclusion of the study. You may withdraw your permission for us to use your information for this research study at any time by sending an email to the Principal Investigator, Michael J. Moritz, MD, at mjmoritz@transplantpregnancyregistry.org.
I have read the above consent for use/disclosure of PHI and verbally consent to participate in the Transplant Pregnancy Registry International.
1. Are you a new member or existing participant in the Registry?*
2. Name*

First NameLast Name
3. Gender*
4. Date of Birth *

MonthDayYear
Date
5. Email*
6. Phone Number*
7. Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
8. Organ Transplanted (there can be more than one response)*

KidneyLiverIntestinePancreasLungHeartOther
9. Name the "Other" in Q.8. (e.g uterus,intestine)

TPRI Registration Form