Registry Brochure
Data Forms
Resources
FDA Pregnancy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
     
 
• Print and View Data Forms for Patients
 
     
 
Adobe Acrobat Reader is required to view and download the slides.
 
 
::: Download Acrobat Reader Here :::
 
     
 
 
 
Information for Patients and Medical Release Forms
 
 
Please read these forms carefully. The Information sheet will tell you about the Registry and what we are asking of you.
 
     
 
The Medical Release Forms will allow us to contact your doctors for information about the pregnancy and the outcome of your pregnancy.
 
     
 
::: Click Here To View Patient Information Sheet :::
 
 
::: Click Here To View Medical Release Forms :::
 
     
 
 
 
Initial Contact Information Form
 
 
(for patients and health care providers)
 
     
 
Information included on this form will allow us to contact you. Complete the portions of the form applicable to you.
 
     
 
::: Click Here To View Initial Contact Form :::
 
     
 
 
 
Data Forms for Pregnant Patients
 
     
 
::: Click Here To View Registration Form :::
 
 
::: Click Here To View Prenatal Test, Medication, and
::: Conncurrent Conditions Form :::
 
     
 
 
 
Data Forms for Male Sexual Partners of Pregnant Patients
 
 
(Males who have taken ribavirin)
 
     
 
::: Click Here To View Male Exposure Form :::
 
     
 
 
 
Click on the appropriate form sets or if there are questions click contact us.
 
     
     
 
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