Clinical Trials Sign-Up Form
Understanding IRDs
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Gene Therapy Sign Up Form

If you are a patient or the guardian of a patient with an IRD and would like to be considered for enrollment, should a clinical trial become available with Dr. Lazar, please fill out the form below.

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Last Name *

First Name *

Email Address *

Phone Number *

Okay to Contact? *

Yes No

Location *

Able to Travel to Los Angeles, CA? *

Yes No

Select the IRD (multiple, if applicable):

Stargardt Disease

Retinitis Pigmentosa

Achromatopsia

Choroideremia

Cone-Rod Dystrophy

Leber Congenital Amaurosis (LCA)

Leber Hereditary Optic Neuropathy (LHON)

Other

Genetic Testing Results, if available (jpg, pdf, png, doc, docx)

Medical/Ocular History Files, if available (jpg, pdf, png, doc, docx)

List of Current Medications, if available (jpg, pdf, png, doc, docx)

Have you participated in a clinical trial before? *

Yes No

Have you ever received eye injections? *

Yes No

If yes, which eye?

Right Left Both

Have you ever had a laser procedure performed on your eye? *

Yes No

If yes, which eye?

Right Left Both

Are you interested in oral medication clinical trials? *

Yes No

Are you interested in eye injection clinical trials? *

Yes No

Are you interested in gene therapy clinical trials? *

Yes No

Are you interested in genetic testing? *

Yes No

Comments / Questions