Patient Request Form

ALS patients who wish to participate in future trials or be considered FOR New Biotic's Compassionate Use Program,, Please complete the form below.

All information Received will be strictly confidential and will not be used for any other purposes.

Patient's Name

First Name

Last Name

Contact's Name (if different from patient)

First Name

Last Name

Contact's Email Address

Contact's Phone (optional)

City and State

How long has the patient been diagnosed with ALS?

Briefly describe current medical condition of patient. For example, include ALS Functional Rating Score history if applicable.

What is the patient's age?

Under 40

40 - 60

Over 60 years old

Is the patient willing to sign a Medical Records Release Form releasing relevant medical history and diagnosis information?

YES

Is the patient willing to sign a Patient Consent and Waiver Form, consenting to the treatment (if chosen to participate), knowing RaphaLX™ is an investigational new drug and knowing all the risks associated with its use?

YES

How did you hear about us?

Patient Request Form

ALS patients who wish to participate in future trials or be considered FOR New Biotic's Compassionate Use Program,, Please complete the form below.

All information Received will be strictly confidential and will not be used for any other purposes.

If You Are Interested In Learning More About THE RaphaLX™ CLINICAL TRIAL, Sign Up To Receive Updates.

Biotherapeutics For Neurological Disorders