Patient Registration  

The Cure JM Foundation is building a database of Juvenile Dermatomyositis and Juvenile Polymyositis sufferers. This information will be used as part of a demographic survey to determine if there are clusters of children affected by JM in the same geographic area. The information you provide will be used exclusively for research, and will not be shared with any other organization or business not connected with this research.
Contact Information:
Required fields are marked with a *

  Dr.    Mr.    Mrs.    Ms.
First Name: *
Last Name: *
Street Address: *
City: *
State: *    Zip: *    Country:
Your phone number: *
Your e-mail address: *
 Relationship to Patient - Choose One:
Parent/Guardian Patient (if 18 or over)
Patient Information:
First Name: *
Last Name: *
 
Street Address: *
City: *

State:  *  Zip:  *  Country: *
Phone number: *
E-mail address: *
Current age: *
Date of Birth: *
Date of Diagnosis: *
Where did symptoms
first appear?
Male Female  *

Type of myositis:

juvenile dermatomyositis

    

juvenile polymyositis

Other 

Join the Cure JM Family Support Network:
The Parent/Child Network was created to give both JM sufferers and parents of children affected by JM the ability to connect and share experiences, questions and concerns. Would you or your child like to join?

Yes   No
If "Yes", who would like to join?
Parent           Child          Both
How would you like to be contacted? e-Mail   Telephone
When is the best time to contact you?

Join Team JM:
Team JM is seeking members who would like to help us raise public awareness of JM, facilitate fundraising efforts, and spread the word about Cure JM. There's no cost to join Team JM, the only thing we require is a passion and desire to eliminate this disease. Would you like to join?

Yes   No

How did you hear about us?

Doctor      Friend      Internet search
Other 

Any comments or suggestions?

  

   
   

This website is provided for educational and informational purposes only. Cure JM is not engaged in rendering medical advice or professional services and this information should not be used for diagnosing or treating a health problem. The site author and the content providers make no representation or warranties, expressed or implied. Providing links to other websites does not imply that Cure JM endorses the information or services provided on those websites. The organizations operating those websites are solely responsible for the content found on their websites.
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