Gender: MaleFemale
Do you want to receive the COVID-19 Vaccine? We offer the Moderna, Pfizer and Johnson & Johnson options at our center: YesNoI am vaccinated
Are you interested in clinical trials?: YesNoMaybe
Do you have sickle cell disease?: YesNo
Do you have sickle cell trait?: YesNo
Race/Ethnicity (required): Black or African-AmericanHispanic or LatinoAmerican Indian or Alaska NativeAsianNative Hawaiian or Other Pacific IslanderWhiteOther
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OPTIONAL: Please confirm your Sickle Cell Disease or Trait Status by uploading your medical record, your most recent visit to the Emergency Room, or a previously dated note from your doctor. You may submit the document in its original format, or a screenshot.
Your information is HIPAA-protected and will not be shared with any third-party. By filling out this form, you agree to be contacted by the Foundation for Sickle Cell Disease Research, to better assist you.