CoRDS Registry Form

If you are interested in enrolling in the CoRDS Registry, please complete the brief screening form below and click submit. Please note CoRDS is a patient-reported registry.  If you are a healthcare provider and wish to refer your patients, please refer them to this form.

If the participant is over the age of 18, and able to enroll themself, they must complete the form below.

If you are a parent of an individual under the age of 18, you may enroll the participant. Please indicate that you are the “Parent”.

If the participant is over the age of 18, and not cognitively able to enroll, and you are the legally authorized representative, you may submit the form below on their behalf. Please indicate that you are the “Legally Authorized Representative”.

  • If you would like to enroll online, CoRDS personnel will send you an email with a username and password needed to enroll via the secure web-based portal.
  • If you would like to enroll by mail, we will send you the CoRDS enrollment forms by mail.

* Required Field

*Who is filling this out?  


 
 
 
 
 
 
 
 
 
 
 

If your preferred enrollment method is mail-based, please provide your mailing address below. (Street address, City, State, Zip code, Province/Region, Country)

 
 
 
 
 
 
 
 
*Would you like to join a disease-specific registry?
(ie: those diagnosed with or at risk for ataxia may select the National Ataxia Foundation registry)
 

 
 

* Required Field

Before submitting this form, please confirm that all contact information (email address, phone number) is correct.

After you submit this form:

CoRDS will send you a log in to enroll via the secure web-based portal within one business day. If you indicated you wanted to enroll by postal mail, we will send you the forms in the mail needed to enroll on the next business day.

Please note, you are not enrolled in the CoRDS Registry until you log in to the secure web-based portal or until you complete the forms and send them back to CoRDS Staff.

To complete online enrollment:

  • Watch for the email from CoRDS with a link and your unique username and password.
  • Log in and complete the consent form and questionnaire.

To complete mail-based enrollment:

  • Watch for the letter from CoRDS with the CoRDS Enrollment forms.
  • Complete the consent form and questionnaire and mail them back to us in the addressed, postmarked envelope provided.

If you have any questions about CoRDS, please contact us at cords@sanfordhealth.org