Patient Registration Form

Sign-up to participate in upcoming therapeutic and diagnostic clinical trials! To register, click on the following link for the Patient Registration Form.

Volunteers are essential to the success of therapeutic and diagnostic clinical trials. Participants contribute to the development of medical research while gaining access to new treatment options that are not yet publicly available.

As part of our therapeutic (rhCFHp) and diagnostic development program, we are recruiting patients today. If you are a patient with any of the following diseases, you are welcome to provide us with your contact information in confidence, and we will contact you at the appropriate time to discuss your potential participation in one of our clinical trials.

Eligible diseases for clinical trial recruitment:

Dense deposit disease (DDD, also called Membranoproliferative Glomerulonephritis or MPGNII)
Atypical hemolytic uremic syndrome (aHUS)
AMD

Again, fill in the Patient Registration Form and we may contact you. The information you provide will be available to Optherion, Inc. and others working on behalf of Optherion in confidence. Please read our Privacy Policy for more information related to the confidentiality of the information you provide to us.

Note that rhCFHp (our lead therapeutic) and our diagnostic services are not yet available in any country though we are seeking to commercialize in various parts of the world.

Please provide us with the following information so that we may contact you about your potential participation in our clinical trials.

The information you submit will be available to Optherion, Inc. and others working on behalf of Optherion. For details regarding the confidentiality of your personal information, please read our Privacy Policy.

Email: *

You are: *

Disease of Patient: *

Disease Other:

If other please specify here

Patient Information

First Name: *

Last Name: *

Address: *

City: *

State/Province: *

Zip Code/Postal Code: *

Country: *

Phone: *

Physician Information

Name: *

Address: *

Phone: *

Opt-In for Additional Information About Our Therapeutics and Diagnostics Program

For updates and more information in the future about our therapeutics or diagnostic services, please check the box below. You may request removal from the Optherion therapeutics and diagnostic services contact list at any time by emailing us at unsubscribeadditionalinformation@optherion.com.

Yes, I wish to receive additional information over time about Optherion’s therapeutics or diagnostic services.

Opt-In for Information About Other Products and Conditions

Optherion and its partners and affiliates may offer additional materials about products and services, health conditions and topics that we believe you may find useful. Additionally, you may be asked for your opinion on these materials and programs. Please check the box below if you would like to receive this additional information and to be contacted about other Optherion products and services, health conditions, and topics in the future. You may request removal from the Optherion additional materials and services contact list at any time by emailing us at unsubscribeotherproducts@optherion.com.

Yes, I wish to receive information about other products and conditions and to be contacted for my opinions about programs and materials.