Contact Us - Amyloidosis Research Consortium

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aria-required="true" type="text" id="tfa_7" name="tfa_7" value="" autocomplete="given-name" title="First Name" class="required"></div> </div> <div class="oneField field-container-D " id="tfa_9-D"> <label id="tfa_9-L" class="label preField reqMark" for="tfa_9">Last Name</label><br><div class="inputWrapper"><input aria-required="true" type="text" id="tfa_9" name="tfa_9" value="" autocomplete="family-name" title="Last Name" class="required"></div> </div> </div> <div id="tfa_417" class="section inline group"> <div class="oneField field-container-D " id="tfa_11-D"> <label id="tfa_11-L" class="label preField reqMark" for="tfa_11">Email address</label><br><div class="inputWrapper"><input aria-required="true" type="text" id="tfa_11" name="tfa_11" value="" autocomplete="email" title="Email address" class="validate-email required"></div> </div> <div class="oneField field-container-D " id="tfa_13-D"> <label id="tfa_13-L" class="label preField " for="tfa_13">Phone number</label><br><div class="inputWrapper"><input type="text" id="tfa_13" name="tfa_13" value="" autocomplete="tel" title="Phone number" class=""></div> </div> </div> <div id="tfa_160" class="section group"> <div class="oneField field-container-D " id="tfa_418-D"> <label id="tfa_418-L" class="label preField " for="tfa_418">Preferred method of contact</label><br><div class="inputWrapper"><select id="tfa_418" name="tfa_418" title="Preferred method of contact" class=""><option value="">Please select...</option> <option value="tfa_419" id="tfa_419" class="">Email</option> <option value="tfa_420" id="tfa_420" class="">Phone</option></select></div> </div> <div class="oneField field-container-D " id="tfa_165-D" role="group" aria-labelledby="tfa_165-L" data-tfa-labelledby="-L tfa_165-L"> <label id="tfa_165-L" class="label preField reqMark" data-tfa-check-label-for="tfa_165" aria-label="I am a... required">I am a...</label><br><div class="inputWrapper"><span id="tfa_165" class="choices horizontal required"><span class="oneChoice"><input type="checkbox" value="tfa_166" class="" id="tfa_166" name="tfa_166" data-conditionals="#tfa_157" aria-labelledby="tfa_166-L" data-tfa-labelledby="tfa_165-L tfa_166-L" data-tfa-parent-id="tfa_165"><label class="label postField" id="tfa_166-L" for="tfa_166"><span class="input-checkbox-faux"></span>Patient</label></span><span class="oneChoice"><input type="checkbox" value="tfa_167" class="" id="tfa_167" name="tfa_167" data-conditionals="#tfa_157,#tfa_262" aria-labelledby="tfa_167-L" data-tfa-labelledby="tfa_165-L tfa_167-L" data-tfa-parent-id="tfa_165"><label class="label postField" id="tfa_167-L" for="tfa_167"><span class="input-checkbox-faux"></span>Potential Patient</label></span><span class="oneChoice"><input type="checkbox" value="tfa_168" class="" id="tfa_168" name="tfa_168" data-conditionals="#tfa_157,#tfa_262" aria-labelledby="tfa_168-L" data-tfa-labelledby="tfa_165-L tfa_168-L" data-tfa-parent-id="tfa_165"><label class="label postField" id="tfa_168-L" for="tfa_168"><span class="input-checkbox-faux"></span>Caregiver</label></span><span class="oneChoice"><input type="checkbox" value="tfa_169" class="" id="tfa_169" name="tfa_169" data-conditionals="#tfa_157,#tfa_262" aria-labelledby="tfa_169-L" data-tfa-labelledby="tfa_165-L tfa_169-L" data-tfa-parent-id="tfa_165"><label class="label postField" id="tfa_169-L" for="tfa_169"><span class="input-checkbox-faux"></span>Patient Family/Friend</label></span><span class="oneChoice"><input type="checkbox" value="tfa_170" class="" id="tfa_170" name="tfa_170" data-conditionals="#tfa_113,#tfa_153,#tfa_278" aria-labelledby="tfa_170-L" data-tfa-labelledby="tfa_165-L tfa_170-L" data-tfa-parent-id="tfa_165"><label class="label postField" id="tfa_170-L" for="tfa_170"><span class="input-checkbox-faux"></span>Nurse</label></span><span class="oneChoice"><input type="checkbox" value="tfa_171" class="" id="tfa_171" name="tfa_171" data-conditionals="#tfa_113,#tfa_153,#tfa_278" aria-labelledby="tfa_171-L" data-tfa-labelledby="tfa_165-L tfa_171-L" data-tfa-parent-id="tfa_165"><label class="label postField" id="tfa_171-L" for="tfa_171"><span class="input-checkbox-faux"></span>Clinician</label></span><span class="oneChoice"><input type="checkbox" value="tfa_172" class="" id="tfa_172" name="tfa_172" data-conditionals="#tfa_113,#tfa_153,#tfa_278" aria-labelledby="tfa_172-L" data-tfa-labelledby="tfa_165-L tfa_172-L" data-tfa-parent-id="tfa_165"><label class="label postField" id="tfa_172-L" for="tfa_172"><span class="input-checkbox-faux"></span>Scientist</label></span><span class="oneChoice"><input type="checkbox" value="tfa_174" class="" id="tfa_174" name="tfa_174" data-conditionals="#tfa_113,#tfa_153" aria-labelledby="tfa_174-L" data-tfa-labelledby="tfa_165-L tfa_174-L" data-tfa-parent-id="tfa_165"><label class="label postField" id="tfa_174-L" for="tfa_174"><span class="input-checkbox-faux"></span>Pharma Representative</label></span><span class="oneChoice"><input type="checkbox" value="tfa_173" class="" id="tfa_173" name="tfa_173" data-conditionals="#tfa_113,#tfa_153" aria-labelledby="tfa_173-L" data-tfa-labelledby="tfa_165-L tfa_173-L" data-tfa-parent-id="tfa_165"><label class="label postField" id="tfa_173-L" for="tfa_173"><span class="input-checkbox-faux"></span>Government</label></span><span class="oneChoice"><input type="checkbox" value="tfa_175" class="" id="tfa_175" name="tfa_175" data-conditionals="#tfa_134,#tfa_113,#tfa_153" aria-labelledby="tfa_175-L" data-tfa-labelledby="tfa_165-L tfa_175-L" data-tfa-parent-id="tfa_165"><label class="label postField" id="tfa_175-L" for="tfa_175"><span class="input-checkbox-faux"></span>Other</label></span></span></div> </div> <div id="tfa_161" class="section inline group"> <div class="oneField field-container-D " id="tfa_134-D"> <label id="tfa_134-L" class="label preField " for="tfa_134">If other, please describe:</label><br><div class="inputWrapper"><input type="text" id="tfa_134" name="tfa_134" value="" data-condition="`#tfa_175`" title="If other, please describe:" class=""></div> </div> <div class="oneField field-container-D " id="tfa_157-D"> <label id="tfa_157-L" class="label preField reqMark" for="tfa_157">Amyloidosis Type</label><br><div class="inputWrapper"><select aria-required="true" id="tfa_157" autocomplete="off" name="tfa_157" data-condition="`#tfa_166` AND NOT (`#tfa_167`) AND NOT (`#tfa_168`) AND NOT (`#tfa_169`)" title="Amyloidosis Type" class="required"><option value="">Please select...</option> <option value="tfa_239" id="tfa_239" class="">AA</option> <option value="tfa_240" id="tfa_240" class="">AL Amyloidosis</option> <option value="tfa_241" id="tfa_241" class="">AB2M</option> <option value="tfa_242" id="tfa_242" class="">ALect2</option> <option value="tfa_243" id="tfa_243" data-conditionals="#tfa_401" class="">Hereditary ATTR</option> <option value="tfa_244" id="tfa_244" data-conditionals="#tfa_401" class="">Hereditary Non-TTR</option> <option value="tfa_245" id="tfa_245" class="">Hereditary Untyped</option> <option value="tfa_246" id="tfa_246" class="">Localized</option> <option value="tfa_247" id="tfa_247" class="">Wild-Type ATTR</option> <option value="tfa_248" id="tfa_248" class="">Untyped</option> <option value="tfa_249" id="tfa_249" data-conditionals="#tfa_274" class="">Other</option></select></div> </div> <div class="oneField field-container-D " id="tfa_262-D"> <label id="tfa_262-L" class="label preField " for="tfa_262">Amyloidosis Type (if known)</label><br><div class="inputWrapper"><select id="tfa_262" autocomplete="off" name="tfa_262" data-condition="`#tfa_167` OR `#tfa_168` OR `#tfa_169`" title="Amyloidosis Type (if known)" class=""><option value="">Please select...</option> <option value="tfa_263" id="tfa_263" class="">AA</option> <option value="tfa_264" id="tfa_264" class="">AL Amyloidosis</option> <option value="tfa_265" id="tfa_265" class="">AB2M</option> <option value="tfa_266" id="tfa_266" class="">ALect2</option> <option value="tfa_267" id="tfa_267" data-conditionals="#tfa_401" class="">Hereditary ATTR</option> <option value="tfa_268" id="tfa_268" data-conditionals="#tfa_401" class="">Hereditary Non-TTR</option> <option value="tfa_269" id="tfa_269" class="">Hereditary Untyped</option> <option value="tfa_270" id="tfa_270" class="">Localized</option> <option value="tfa_271" id="tfa_271" class="">Wild-Type ATTR</option> <option value="tfa_272" id="tfa_272" class="">Untyped</option> <option value="tfa_273" id="tfa_273" data-conditionals="#tfa_274" class="">Other</option></select></div> </div> <div class="oneField field-container-D " id="tfa_274-D"> <label id="tfa_274-L" class="label preField " for="tfa_274">If other type, please explain:</label><br><div class="inputWrapper"><input type="text" id="tfa_274" name="tfa_274" value="" data-condition="`#tfa_249` OR `#tfa_273`" title="If other type, please explain:" class=""></div> </div> <div id="tfa_400" class="section inline group"> <div class="oneField field-container-D hintsBelow " id="tfa_401-D"> <label id="tfa_401-L" class="label preField " for="tfa_401">Genetic Variant (if known)</label><br><div class="inputWrapper"> <select id="tfa_401" name="tfa_401" data-condition="`#tfa_267` OR `#tfa_244` OR `#tfa_268` OR `#tfa_243`" title="Genetic Variant (if known)" aria-describedby="tfa_401-HH" class=""><option value="">Please select...</option> <option value="tfa_402" id="tfa_402" class="">Glu54Gly</option> <option value="tfa_403" id="tfa_403" class="">Ile68Leu</option> <option value="tfa_404" id="tfa_404" class="">Ile84Ser</option> <option value="tfa_405" id="tfa_405" class="">Phe64Leu</option> <option value="tfa_406" id="tfa_406" class="">Ser77Tyr</option> <option value="tfa_407" id="tfa_407" class="">Thr60Ala</option> <option value="tfa_408" id="tfa_408" class="">Val122Ile</option> <option value="tfa_409" id="tfa_409" class="">Val30Met</option> <option value="tfa_410" id="tfa_410" data-conditionals="#tfa_416" class="">APOA1</option> <option value="tfa_411" id="tfa_411" data-conditionals="#tfa_415" class="">Gelsolin</option> <option value="tfa_412" id="tfa_412" data-conditionals="#tfa_414" class="">Other</option> <option value="tfa_413" id="tfa_413" class="">Unsure</option></select><span class="field-hint-inactive" id="tfa_401-H"><span id="tfa_401-HH" class="hint">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.</span></span> </div> </div> <div class="oneField field-container-D " id="tfa_414-D"> <label id="tfa_414-L" class="label preField " for="tfa_414">Other genetic variant, if known:</label><br><div class="inputWrapper"> <input type="text" id="tfa_414" name="tfa_414" value="" autocomplete="off" aria-describedby="tfa_414-HH" data-condition="`#tfa_412`" title="Other genetic variant, if known:" class=""><span class="field-hint-inactive" id="tfa_414-H"><span id="tfa_414-HH" class="hint">Should be in the format "Abc12Abc" or "Abc123Abc", ex: Val30Met</span></span> </div> </div> <div class="oneField field-container-D " id="tfa_415-D"> <label id="tfa_415-L" class="label preField " for="tfa_415">Gelsolin Type, if known:</label><br><div class="inputWrapper"> <input type="text" id="tfa_415" name="tfa_415" value="" autocomplete="off" aria-describedby="tfa_415-HH" data-condition="`#tfa_411`" title="Gelsolin Type, if known:" class=""><span class="field-hint-inactive" id="tfa_415-H"><span id="tfa_415-HH" class="hint"><span style="font-size: 12.92px;">Should be in the format "Abc12Abc" or "Abc123Abc", ex: </span>Asp187Asn</span></span> </div> </div> <div class="oneField field-container-D " id="tfa_416-D"> <label id="tfa_416-L" class="label preField " for="tfa_416"><span style="border: 0px solid rgb(227, 227, 227); --tw-border-spacing-x: 0; --tw-border-spacing-y: 0; --tw-translate-x: 0; --tw-translate-y: 0; --tw-rotate: 0; --tw-skew-x: 0; --tw-skew-y: 0; --tw-scale-x: 1; --tw-scale-y: 1; --tw-pan-x: ; --tw-pan-y: ; --tw-pinch-zoom: ; --tw-scroll-snap-strictness: proximity; --tw-gradient-from-position: ; --tw-gradient-via-position: ; --tw-gradient-to-position: ; --tw-ordinal: ; --tw-slashed-zero: ; --tw-numeric-figure: ; --tw-numeric-spacing: ; --tw-numeric-fraction: ; --tw-ring-inset: ; --tw-ring-offset-width: 0px; --tw-ring-offset-color: #fff; --tw-ring-color: rgba(69,89,164,.5); --tw-ring-offset-shadow: 0 0 transparent; --tw-ring-shadow: 0 0 transparent; --tw-shadow: 0 0 transparent; --tw-shadow-colored: 0 0 transparent; --tw-blur: ; --tw-brightness: ; --tw-contrast: ; --tw-grayscale: ; --tw-hue-rotate: ; --tw-invert: ; --tw-saturate: ; --tw-sepia: ; --tw-drop-shadow: ; --tw-backdrop-blur: ; --tw-backdrop-brightness: ; --tw-backdrop-contrast: ; --tw-backdrop-grayscale: ; --tw-backdrop-hue-rotate: ; --tw-backdrop-invert: ; --tw-backdrop-opacity: ; --tw-backdrop-saturate: ; --tw-backdrop-sepia: ; color: rgb(13, 13, 13); font-family: Söhne, ui-sans-serif, system-ui, -apple-system, "Segoe UI", Roboto, Ubuntu, Cantarell, "Noto Sans", sans-serif, "Helvetica Neue", Arial, "Apple Color Emoji", "Segoe UI Emoji", "Segoe UI Symbol", "Noto Color Emoji"; font-size: 16px; white-space-collapse: preserve;">APOA1 </span>Type, if known:</label><br><div class="inputWrapper"> <input type="text" id="tfa_416" name="tfa_416" value="" autocomplete="off" aria-describedby="tfa_416-HH" data-condition="`#tfa_410`" title="APOA1 Type, if known:" class=""><span class="field-hint-inactive" id="tfa_416-H"><span id="tfa_416-HH" class="hint"><span style="font-size: 12.92px;">Should be in the format "Abc12Abc" or "Abc123Abc", ex: </span>Glu34Lys</span></span> </div> </div> </div> <div id="tfa_154" class="section inline group"> <div class="oneField field-container-D " id="tfa_113-D"> <label id="tfa_113-L" class="label preField " for="tfa_113">Organization</label><br><div class="inputWrapper"><input type="text" id="tfa_113" name="tfa_113" value="" data-condition="`#tfa_170` OR `#tfa_171` OR `#tfa_172` OR `#tfa_174` OR `#tfa_173` OR `#tfa_175`" title="Organization" class=""></div> </div> <div class="oneField field-container-D " id="tfa_153-D"> <label id="tfa_153-L" class="label preField " for="tfa_153">Professional Title</label><br><div class="inputWrapper"><input type="text" id="tfa_153" name="tfa_153" value="" data-condition="`#tfa_170` OR `#tfa_171` OR `#tfa_172` OR `#tfa_174` OR `#tfa_173` OR `#tfa_175`" title="Professional Title" class=""></div> </div> <div class="oneField field-container-D " id="tfa_278-D"> <label id="tfa_278-L" class="label preField " for="tfa_278">Specialty</label><br><div class="inputWrapper"><select id="tfa_278" name="tfa_278" data-condition="`#tfa_170` OR `#tfa_171` OR `#tfa_172`" title="Specialty" class=""><option value="">Please select...</option> <option value="tfa_279" id="tfa_279" class="">AL Amyloidosis</option> <option value="tfa_280" id="tfa_280" class="">ATTR Amyloidosis</option> <option value="tfa_281" id="tfa_281" class="">Cardiology</option> <option value="tfa_282" id="tfa_282" class="">Gastroenterology</option> <option value="tfa_283" id="tfa_283" class="">Hematology</option> <option value="tfa_284" id="tfa_284" class="">Immunology</option> <option value="tfa_285" id="tfa_285" class="">Nephrology</option> <option value="tfa_286" id="tfa_286" class="">Oncology</option> <option value="tfa_287" id="tfa_287" class="">Pulmonology</option> <option value="tfa_288" id="tfa_288" class="">Radiology</option> <option value="tfa_289" id="tfa_289" class="">Rheumatology</option> <option value="tfa_290" id="tfa_290" data-conditionals="#tfa_423" class="">Other</option></select></div> </div> <div class="oneField field-container-D " id="tfa_423-D"> <label id="tfa_423-L" class="label preField " for="tfa_423">If other Specialty, please explain:</label><br><div class="inputWrapper"><input type="text" id="tfa_423" name="tfa_423" value="" data-condition="`#tfa_290`" title="If other Specialty, please explain:" class=""></div> </div> </div> <div class="htmlSection" id="tfa_129"><div class="htmlContent" id="tfa_129-HTML"><i style=""><span style="font-size: 15.2px;">ARC does not share this information with outside organizations.<br></span></i></div></div> </div> </div> <div id="tfa_117" class="section inline group"> <div class="oneField field-container-D " id="tfa_114-D"> <label id="tfa_114-L" class="label preField " for="tfa_114">Address Line 1</label><br><div class="inputWrapper"> <input type="text" id="tfa_114" name="tfa_114" value="" autocomplete="no-address-autocomplete" title="Address Line 1" data-dataset-allow-free-responses="1" data-dataset-clear-cache="" data-dataset-timestamp="1711391037" data-dataset-id="3390be42-d3ba-4f41-8f61-6c34f852020e" data-dataset-map="b=tfa_118,c=tfa_121,d=tfa_119,e=tfa_122," data-dataset-type="address-autocomplete" data-dataset-url="https://arci.tfaforms.net/api_v2/datasets" class="wfAutosuggest"><i class="fa fa-spinner fa-pulse fa-fw tt-spinner"></i><i class="fa fa-search tt-search" aria-hidden="true"></i><i class="fa fa-times-circle tt-clear no-input" tabindex="0" aria-label="Clear field" role="button"></i> </div> </div> <div class="oneField field-container-D " id="tfa_116-D"> <label id="tfa_116-L" class="label preField " for="tfa_116">Address Line 2</label><br><div class="inputWrapper"><input type="text" id="tfa_116" name="tfa_116" value="" autocomplete="address-line2" title="Address Line 2" class=""></div> </div> </div> <div id="tfa_120" class="section inline group"> <div class="oneField field-container-D " id="tfa_118-D"> <label id="tfa_118-L" class="label preField " for="tfa_118">City/Town</label><br><div class="inputWrapper"><input type="text" id="tfa_118" name="tfa_118" value="" title="City/Town" class=""></div> </div> <div class="oneField field-container-D " id="tfa_119-D"> <label id="tfa_119-L" class="label preField " for="tfa_119">State/Province</label><br><div class="inputWrapper"><input type="text" id="tfa_119" name="tfa_119" value="" title="State/Province" class=""></div> </div> </div> <div id="tfa_123" class="section inline group"> <div class="oneField field-container-D " id="tfa_121-D"> <label id="tfa_121-L" class="label preField " for="tfa_121">Postal Code</label><br><div class="inputWrapper"><input type="text" id="tfa_121" name="tfa_121" value="" autocomplete="postal-code" title="Postal Code" class="validate-alphanum"></div> </div> <div class="oneField field-container-D " id="tfa_122-D"> <label id="tfa_122-L" class="label preField " for="tfa_122">Country</label><br><div class="inputWrapper"><input type="text" id="tfa_122" name="tfa_122" value="" autocomplete="country" title="Country" class=""></div> </div> </div> </div> <div class="oneField field-container-D " id="tfa_422-D"> <label id="tfa_422-L" class="label preField reqMark" for="tfa_422">How can we help you?</label><br><div class="inputWrapper"><textarea aria-required="true" id="tfa_422" name="tfa_422" title="How can we help you?" class="required"></textarea></div> </div> <input type="hidden" id="tfa_105" name="tfa_105" value="Email Inquiry" class=""><div id="tfa_424" class="section inline group"> <div class="oneField field-container-D " id="tfa_425-D"> <label id="tfa_425-L" class="label preField " for="tfa_425">How Did You Hear About ARC?</label><br><div class="inputWrapper"><select id="tfa_425" name="tfa_425" title="How Did You Hear About ARC?" class=""><option value="">Please select...</option> <option value="tfa_426" id="tfa_426" class="">Web Search (Google, etc.)</option> <option value="tfa_427" id="tfa_427" data-conditionals="#tfa_439" class="">Referral from Healthcare Provider</option> <option value="tfa_428" id="tfa_428" data-conditionals="#tfa_434" class="">Social Media</option> <option value="tfa_429" id="tfa_429" data-conditionals="#tfa_440" class="">Patient Support Group or Patient Advocate</option> <option value="tfa_430" id="tfa_430" class="">Friend or Family Member</option> <option value="tfa_431" id="tfa_431" class="">Colleague or Employer</option> <option value="tfa_432" id="tfa_432" data-conditionals="#tfa_433" class="">Other</option></select></div> </div> <div class="oneField field-container-D " id="tfa_433-D"> <label id="tfa_433-L" class="label preField " for="tfa_433">Please tell us how you heard about ARC:</label><br><div class="inputWrapper"><input type="text" id="tfa_433" name="tfa_433" value="" autocomplete="off" data-condition="`#tfa_432`" title="Please tell us how you heard about ARC:" class=""></div> </div> <div class="oneField field-container-D " id="tfa_434-D"> <label id="tfa_434-L" class="label preField " for="tfa_434">Please specify which social media site you found us on:</label><br><div class="inputWrapper"> <select id="tfa_434" name="tfa_434" data-condition="`#tfa_428`" title="Please specify which social media site you found us on:" aria-describedby="tfa_434-HH" class=""><option value="">Please select...</option> <option value="tfa_435" id="tfa_435" class="">Facebook</option> <option value="tfa_436" id="tfa_436" class="">LinkedIn</option> <option value="tfa_437" id="tfa_437" class="">Twitter (X)</option> <option value="tfa_438" id="tfa_438" class="">YouTube</option></select><span class="field-hint-inactive" id="tfa_434-H"><span id="tfa_434-HH" class="hint">Knowing which social media site you found us on helps us tailor our efforts and better connect with others.</span></span> </div> </div> <div class="oneField field-container-D " id="tfa_439-D"> <label id="tfa_439-L" class="label preField " for="tfa_439">Please specify the healthcare provider/clinic who referred you (optional):</label><br><div class="inputWrapper"> <input type="text" id="tfa_439" name="tfa_439" value="" autocomplete="off" aria-describedby="tfa_439-HH" data-condition="`#tfa_427`" title="Please specify the healthcare provider/clinic who referred you (optional):" class=""><span class="field-hint-inactive" id="tfa_439-H"><span id="tfa_439-HH" class="hint">If a doctor or clinic helped, please share their name. It helps us track connections and show our appreciation!</span></span> </div> </div> <div class="oneField field-container-D " id="tfa_440-D"> <label id="tfa_440-L" class="label preField " for="tfa_440">Please specify the support group or patient advocate who referred you (optional):</label><br><div class="inputWrapper"> <input type="text" id="tfa_440" name="tfa_440" value="" autocomplete="off" aria-describedby="tfa_440-HH" data-condition="`#tfa_429`" title="Please specify the support group or patient advocate who referred you (optional):" class=""><span class="field-hint-inactive" id="tfa_440-H"><span id="tfa_440-HH" class="hint">If a group or patient advocate helped, please share their name. 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