Fields marked with an * are required.

First Name *

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Last Name *

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Phone number *

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Email 

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Date of Birth MM/DD/YYYY *

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ZIP or Postal Code *

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Are you Male or Female? Please select one... Male Female Prefer not to say

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Have you been diagnosed with Gout? * Please select one… Yes – I have Gout No

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Do you have an allergy to any of the following medications? *

• Colchicine
• Non-Steroidal Anti-Inflammatory Drugs (NSAIDs – e.g., Advil, Tylenol, Aleve, Naproxen)
• Aspirin

Please select one... Yes – I am allergic to Colchicine Yes – I am allergic to Non-Steroidal Anti-Inflammatory Drugs Yes – I am allergic to aspirin No – I am not allergic to the above

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Have you ever taken Krystexxa (Pegloticase) for your Gout? * Please select one… Yes No Unsure

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Have you been diagnosed (by a doctor) with any other medical conditions? *
(For example: Rheumatoid arthritis, Human immunodeficiency virus (HIV), Hepatitis B, Hepatitis C, myositis/myopathy, rhabdomyolysis, Stevens-Johnson syndrome, toxic epidermal necrolysis, xanthinuria)
Please list here or write 'none'
Please only include conditions which have been diagnosed by a doctor.

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Are you taking any medications for your Gout or other health conditions? *
Please list them below or type ‘none’.

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Please, select your height from the dropdown below. * Please select one... 4'0" 4'1" 4'2" 4'3" 4'4" 4'5" 4'6" 4'7" 4'8" 4'9" 4'10" 4'11" 5'0" 5'1" 5'2" 5'3" 5'4" 5'5" 5'6" 5'7" 5'8" 5'9" 5'10" 5'11" 6'0" 6'1" 6'2" 6'3" 6'4" 6'5" 6'6" 6'7" 6'8" 6'9" 6'10" 6'11"

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How much do you weigh in Lbs (pounds)? *

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If female, are you currently pregnant or breastfeeding? * Please select one… Yes No N/A- Male

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What is the best day/time to reach you via telephone (we know you are busy)? *

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Would you like to be contacted about taking part in a Clinical Trial? *

Yes

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