PATIENTS 

If you have Stargardt disease and want to stay informed about our research, please complete the following form below.

As Stargardt disease is very rare, the information below will help us better understand the disease.

No identifiable information (such as name, email or phone number) will be disclosed to any 3rd party. We will use your information to contact you or your physician about upcoming trials.

If you know anyone else with Stargardt disease, please let them know about our research.

Alkeus Pharmaceuticals takes your personal information seriously. The information you provide will only be used by Alkeus Pharmaceuticals to send you additional questions, updates on trials, or other helpful news on Stargardt disease trials and research.

STARGARDT DISEASE CONTACT FORM

  • First Name
  • Last Name
  • City
  • Country
  • Zip Code
  • Telephone
  • Current Age
  • Email
  • Age upon which visual problems started?

  • Vision of best seeing eye previously (20/xxx)?

  • Vision of best seeing eye today (20/xxx)?
  • Have you been genetically confirmed for Stargardt (Yes/No)?
  • If yes, please enter detected ABCA4 genetic mutation(s)
  • Name of your ophthalmologist
  • Contact information of your ophthalmologist (phone, email or both)
  • If <18 years old, please enter name of parent or legal representative:
  • If filling out for someone else, please enter your name
  • By submitting this form you agree to the following terms:

    (1) There is no guarantee you will be enrolled in any clinical trial,

    (2) There is no guarantee that there ever will be a clinical trial, and (3) You authorize Alkeus Pharmaceuticals and parties acting on its behalf to contact you

  • To be removed from our database, please email us at info@alkeus.com