Form

Join the movement

We are thrilled to hear about your interest in joining Citizen Health! We are currently considering groups in the Rare Disease space and would love to learn more about your organization and community.

Once you complete the form, we will review your submission and follow up with you in the next 1-2 weeks to explain the next steps in your journey with us.

We can't wait to hear from you.

First name*

Last name*

Email*

Organization name*

Please provide a link to your organization's website*

Job title

Is your organization registered as a 501c3 non-profit?*

Yes

Tell us more how did you hear about us (e.g., which search term? conference / event? who referred you?)

Why are you interested in joining Citizen*

Tell us more about the disease your organization supports.

What condition(s) does your organization support (include genes if applicable)*

To the best of your knowledge, how many patients are diagnosed worldwide?

What stage of drug development best characterizes your disease (select all that applies)*

Basic science

Translational science - testing therapies in cell lines, animal models..

Phase 1/2 clinical trial

Phase 3 clinical trial

Approved drugs on market

We hope to learn more about your existing research infrastructure and how you engage your community.

Do you have an existing patient registry and/or natural history study?*

YES, we have both

YES, we have a patient registry, but not a natural history study

YES, we have a natural history study, but not a patient registry

YES, we have something but I'm confused about the difference between the two

NO, we don't have them but we plan to create or collaborate on one

NO, we don't have them and we have no plan to create or collaborate on one

If YES, can you share current tool / platform / provider used for your Registry and Natural History Study?

How many unique patients do you currently have in your contact database? How many of them are in the US?*

How many US patients do you think you can recruit to join Citizen in the first 6 month period of joining?*