National Psoriasis Foundation

BioBank registration form

The National Psoriasis Foundation Victor Henschel BioBank is a resource for scientists to study the genetics of psoriasis. By completing this form you are registering to participate in the BioBank and agree to receive communications from the BioBank team. If you have any questions, please contact the BioBank team at biobank@psoriasis.org, or call 800.723.9166.

Due to study criteria, not everyone will qualify for the BioBank. Please review our criteria for participation before completing this form.

Donor information
* Required
Title
* First name
Middle name
* Last name
Suffix
* Street address 1
Street address 2
* City
* State
* ZIP/mail code
* Phone (evening)
Phone (daytime)
* E-mail address
 
(The National Psoriasis Victor Henschel BioBank does
not share your contact information with anyone.)
 
How did you hear about the BioBank?
 
I would like to receive communications from the National Psoriasis Foundation.
* Gender Male Female
* Date of birth: Month   Day   Year
 
* Choose one of the following:
I have psoriasis and/or psoriatic arthritis. I am interested in being a case participant for the BioBank.
I do not have psoriasis or psoriatic arthritis. I am interested in being a control participant for the BioBank.
 
Please read and check the following statements:
* I agree to complete the BioBank consent form and the BioBank diagnosis confirmation form (if applicable).
* I agree to donate two tubes of blood and swab of cheek cells.
* I agree to complete the BioBank clinical questionnaire form.
* I am willing to share my medical records and/or confirmation of diagnosis.
* I am willing to remain in contact with the National Psoriasis Victor Henschel BioBank for at least 5 years, to keep my records up to date.
* I am willing to be re-contacted if additional samples are needed.
* I understand that only one person in my immediate family can participate in the BioBank. "Immediate family" is defined as grandparents, parents, siblings, children and grandchildren.
 
Self assessment
* Required
 
Please indicate if you or anyone in your immediate family have/has any of the following diseases. (Glossary of terms).

Note: The presence of any condition besides psoriasis or psoriatic arthritis is a disqualifying factor. Read more about our criteria for participation.

Name of disease Yes No Don't know
* Psoriasis
* Psoriatic arthritis
* Alopecia areata
* Atopic dermatitis
* Crohn's disease
* Cutaneous T-Cell Lymphoma (CTCL)
* Eczema
* Juvenile-onset diabetes (type I)
* Lupus
* Multiple sclerosis
* Rheumatoid arthritis
* Ulcerative colitis
* Have you ever donated a blood sample to a tissue bank or other psoriasis-related research study?
Yes
No
 
If you are registering to be a control participant, please stop here.
If you are registering to be a case participant, please continue.
 
Psoriasis assessment
* Required if you have psoriasis and wish to participate as a psoriasis case study
 
* Do you have psoriasis?
Yes
No
Don't know
 
If you answered yes, please continue. If you answered no, please go to the psoriatic arthritis section.
 
* Your age when you were first diagnosed with psoriasis
 
* Name of a certified dermatologist who can verify your diagnosis
* City
* State
 
Psoriatic arthritis assessment
* Required if you have psoriatic arthritis and want to participate as a case study.
 
* Do you have psoriatic arthritis?
Yes
No
Don't know
 
If you answered yes, please continue. If you answered no, please stop here.
 
* Your age when you were first diagnosed with psoriatic arthritis
 
* Name of a certified rheumatologist who can verify your diagnosis
* City
* State

The National Psoriasis BioBank is an important strategy for finding a cure. This program could not take place without the commitment and dedication of the psoriasis community and individuals like you. Thank you for your continued support.

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Copyright ©2008 National Psoriasis Foundation/USA