Title / Prefix
Optional
First Name
Middle Name
Optional
Last Name
Suffix (e.g., Jr., Sr., III)
If Applicable
Email address
Phone number
Preferred method of contact
Please select...
Email
Phone
I am a...
Patient
Potential Patient
Caregiver
Patient Family/Friend
Nurse
Clinician
Scientist
Pharma Representative
Government
Other
If other, please describe:
Amyloidosis Type
Please select...
AA
AL Amyloidosis
AB2M
ALect2
Hereditary ATTR
Hereditary Non-TTR
Hereditary Untyped
Localized
Wild-Type ATTR
Untyped
Other
Amyloidosis Type (if known)
Please select...
AA
AL Amyloidosis
AB2M
ALect2
Hereditary ATTR
Hereditary Non-TTR
Hereditary Untyped
Localized
Wild-Type ATTR
Untyped
Other
If other type, please explain:
Genetic Variant (if known)
Please select...
Glu54Gly
Ile68Leu
Ile84Ser
Phe64Leu
Ser77Tyr
Thr60Ala
Val122Ile
Val30Met
APOA1
Gelsolin
Other
Unsure
There are many known variants - some of the more common ones are listed here. Please select "other" if you don't find yours among this list.
Other genetic variant, if known:
Should be in the format "Abc12Abc" or "Abc123Abc", ex: Val30Met
Gelsolin Type, if known:
Should be in the format "Abc12Abc" or "Abc123Abc", ex:
Asp187Asn
APOA1
Type, if known:
Should be in the format "Abc12Abc" or "Abc123Abc", ex:
Glu34Lys
Organization
Professional Title
Specialty
Please select...
AL Amyloidosis
ATTR Amyloidosis
Cardiology
Gastroenterology
Hematology
Immunology
Nephrology
Oncology
Pulmonology
Radiology
Rheumatology
Other
If other Specialty, please explain:
ARC does not share this information with outside organizations.
Address Line 1
Address Line 2
City/Town
State/Province
Postal Code
Country
How can we help you?
How Did You Hear About ARC?
Please select...
Web Search (Google, etc.)
Referral from Healthcare Provider
Social Media
Patient Support Group or Patient Advocate
Friend or Family Member
Colleague or Employer
Other
Please tell us how you heard about ARC:
Please specify which social media site you found us on:
Please select...
Facebook
LinkedIn
Twitter (X)
YouTube
Knowing which social media site you found us on helps us tailor our efforts and better connect with others.
Please specify the healthcare provider/clinic who referred you (optional):
If a doctor or clinic helped, please share their name. It helps us track connections and show our appreciation!
Please specify the support group or patient advocate who referred you (optional):
If a group or patient advocate helped, please share their name. It helps us track connections and show our appreciation!
reCAPTCHA helps prevent automated form spam.
The submit button will be disabled until you complete the CAPTCHA.