ICRS Patient Registry - New User Request Form
Please complete all fields below. Your responses will help us evaluate your application and understand how best to support and engage you within the Registry community. All data is handled according to applicable data protection standards.
1. Personal & Institutional Information
First Name
*
Last Name
*
Email
*
example@example.com
Phone Number (include international code)
*
-
Area Code
Phone Number
LinkedIn Profile
Instagram Profile
Facebook Profile
YouTube Channel
Medical Registration Number (issued by national medical council or licensing body)
*
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Address
*
Hospital / Institution
Street Address
City
State / Province
Postal / Zip Code
2. Engagement Preferences
Would you like us to tag you on our ICRS social media platforms as a new member?
*
Yes
No
How did you learn about the ICRS Patient Registry?
Are you currently an ICRS member?
*
Yes
No
If No: Why not? Do you plan to become one?
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3. Clinical Practice Information
Do you treat cartilage patients?
*
Yes
No
If Yes: Approximately how many per month?
Please describe your interest in the registry (e.g., monitor my patients, researcher, patient advocate, etc.)
*
Do your patients primarily speak English?
*
Yes
No
If No: Please list other language(s) spoken.
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4. Registry Engagement Goals
Why are you registering to use the ICRS Patient Registry? (select all that apply)
*
To improve patient outcomes
To meet hospital quality improvement goals
To support access or reimbursement efforts
To contribute to scientific or policy research
Other (Please specify)
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5. Participation Interests
Are you interested in attending a training webinar for new users?
*
Yes
No
Are you interested in becoming a country ambassador?
*
Yes
No
If Yes: What country/region would you like to support?
Are you interested in learning more about joining the Steering Committee in the future?
*
Yes
No
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6. Data Protection
Please confirm that you have obtained patient consent and regional/institutional ethical approvals to input any patient-identifiable data.
*
I confim
Submit
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