Patient Registry

 

This is a patient registry form for anyone who has a medical disorder who would like to join. Just sign in the following categories. Once you're done, click Submit.  All information is handled under HIPAA Compliance laws. All data will be held confidentially, obtained voluntarily, and will never be shared with third parties. If a research study is initiated for your condition, you may be contacted.

 

* - The required fields that need to be filled in.

© 2020 John Paul II Medical Research Institute.

Address:

John Paul II Medical Research Institute
2500 Crosspark Rd

Suite W230
Coralville, IA 52241

Phone: (319) 688-7367

Fax: (319) 887-2870