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VPREG_SpanishConsent

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Consentimiento para participar en el Registro de Embarazos y Vasculitis (V-PREG)

Nombre*
Nombre de pila Apellido
Email*
Eres mujer*
- Si
- No
Fecha de nacimiento*
MM slash DD slash YYYY
¿Es usted un paciente con vasculitis?*
- Si
- No
Confirme qué tipo de vasculitis tiene. (Seleccione solo UNO)*
- Arteritis De Células Gigantes
- Arteritis de Takayasu (TAK)
- Enfermedad de Behçet
- El síndrome de Churg-Strauss
- Granulomatosis con poliangitis (granulomatosis de Wegener)
- Poliangeítis microscópica (PAM)
- Poliarteritis nudosa (PAN)
- Púrpura de Henoch-Schönlein (vasculitis por IgA)
- Vasculitis crioglobulinémica
- Vasculitis del sistema nervioso central (SNC)
- Vasculitis urticaria
¿Estás embarazada?*
- Si
- No
Fecha de vencimiento del embarazo*
MM slash DD slash YYYY
¡Únete ahora!*
Acepto participar en el Registro de Embarazos y Vasculitis (V-PREG).
Esperamos con interés poder escuchar su respuesta mientras pasa por su embarazo; le haremos preguntas sobre cómo está haciendo su vasculitis, qué medicamentos está tomando y cómo progresa su embarazo.

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Our Mission

Building upon the collective strength of the vasculitis community, the Foundation supports, inspires and empowers individuals with vasculitis and their families through a wide range of education, research, clinical, and awareness initiatives.

The Vasculitis Foundation is a registered 501 (c) (3) non-profit organization. All contributions are 100% tax-deductible.

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Mail:
Vasculitis Foundation
PO Box 28660
Kansas City, MO 64188
1.816.436.8211 or 1.800.277.9474

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