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    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?:
    Do you have sickle cell disease?:
    Do you have sickle cell trait?:
    Race/Ethnicity (required):
    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.