Form

Stevens Johnson Syndrome / Toxic Epidermal Necrolysis

Please complete the survey below. Thank You!
Thank you for your interest in the SJS Research Consortium Study.

You are invited to complete this pre-screening survey to see if you might be a good fit for the Genetic Risk and Long-Term Ocular Outcomes in SJS/TEN study. You do not need to have a history of ocular disease to participate.
Are you interested in learning more about this research study?

YesNo
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address

Street Address

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CityState / Province

Postal / Zip Code
Have you been diagnosed with SJS / TEN?

YesNo
How long hospital stay?

1 week4 weeksLonger
Was your SJS/TEN caused by a Medication?

LamitcalBactrimOther
To confirm SJS / TEN diagnosis for the study, would you be willing to submit medical records to our research team?

YesNo
Do you give us permission to retain your information and contact you with future drug hypersensitivity study opportunities?

YesNo
Do you give your us permission to keep your answers on file and contact you regarding your willingness to participate in future studies about drug hypersensitivity?

YesNo, I would like my answers and contact information destroyed when the SJS Research Consortium Survey is over.
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