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Education
Pediatrics
Living Well
Treatments/Research
Resources
Ways to Give
Connect
Contact Us

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NEWLY DIAGNOSED

About
Education
Pediatrics
Living Well
Treatments/Research
Resources
Ways to Give
Connect
Contact Us

About
Education
Pediatrics
Living Well
Treatments/Research
Resources
Ways to Give
Connect
Contact Us

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Vasculitis Pregnancy Registry Consent Form

Vasculitis Pregnancy Registry Consent Form

VPREG Consent Form

First Name(Required)

Last Name(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Email(Required)

Are you female?(Required)

Yes

No

Are you a patient with vasculitis?(Required)

Yes

No

Please confirm which type of vasculitis you have? (Please select only ONE)(Required)

Behçet’s Disease

Central Nervous System (CNS) Vasculitis

Cryoglobulinemic vasculitis (Cryoglobulinemia)

Eosinophilic Granulomatosis with Polyangiitis (also called Churg-Strauss Syndrome)

Giant Cell (Temporal) Arteritis (GCA)

Granulomatosis with Polyangiitis (also called Wegener’s granulomatosis or GPA)

Henoch-Schönlein Purpura (IgA vasculitis)

Microscopic Polyangiitis (MPA)

Polyarteritis Nodosa (PAN)

Takayasu Arteritis (TAK)

Urticarial Vasculitis

Other/Suspected Diagnosis

Are you currently pregnant?(Required)

Yes

No

Pregnancy Due Date(Required)

MM slash DD slash YYYY

Join the Study(Required)

I agree to participate in the Vasculitis Pregnancy study.

We are looking forward to hearing from you as you go through your pregnancy – we will ask questions about how your vasculitis is doing, what medications you are taking, and how your pregnancy progresses.

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PO Box 28660, Kansas City, MO 64188
1.816.436.8211 or 1.800.277.9474

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Help us raise $100,000 to create more life-changing connections

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$25 welcomes new support group members
$50 shares vital educational resources
$100 connects patients with vasculitis experts
$250 brings our community together through events
$500 promotes awareness and early detection