Please complete the form below if you would like to learn more about our current clinical trials. Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Phone NumberHave you been diagnosed with Thyroid Eye Disease (TED) or have symptoms of TED?Please Select an optionPlease Select an optionYesNoNot surePrefer not to sayWhen were you diagnosed with Thyroid Eye Disease (TED)?Please Select an optionPlease Select an optionWithin the past 6 monthsWithin the past 12 monthsMore than a 15 months agoNot sureNot diagnosedHave you been diagnosed with Graves' Disease?Please Select an optionPlease Select an optionYesNoNot sureHow long have you had Thyroid Eye Disease (TED) symptoms?Please Select an optionPlease Select an optionLess than 12 monthsMore than 12 monthsNot surePrefer not to saySelect the symptoms of Thyroid Eye Disease (TED) that you are experiencing:Dry eyesIrritated eyesWatery eyesRed eyesBulging eyesDouble visionDifficulty closing eyesPain behind the eyePain with eye movementBlurrinessEyelid swellingLight sensitivityOtherNot sureNone of the aboveHave you ever been treated with Tepezza?Please Select an optionPlease Select an optionYesNoNot surePrefer not to sayHave you ever had irradiation or surgery to treat your Thyroid Eye Disease (TED)?Please Select an optionPlease Select an optionYesNoNot surePrefer not to sayHave you ever done radioactive iodine therapy to treat your Thyroid Eye Disease (TED)?Please Select an optionPlease Select an optionYesNoNot surePrefer not to sayDo you have a history of any of the following conditions?ImmunodeficiencyOrgan transplantTuberculosisStroke, pulmonary embolism or blood clotsAtrial fibrillation, heart attack or anginaInflammatory bowel disease such as Crohn's Disease or Ulcerative ColitisMultiple sclerosisNeurological conditionCancerHeart failureBleeding conditionSystemic lupus erythematosusSerious infectionGastrointestinal perforation or abscessOther major medical conditionNone of the aboveAre you currently using any of the following medications?Please Select an optionPlease Select an optionGlucocorticoidsNon-steroid immunosuppressive agentBiotinSeleniumAnticoagulant therapyNone of the aboveNot surePrefer not to sayHave you participated in any other clinical trials?Please Select an optionPlease Select an optionI am currently participatingYes, in the past 30 daysYes, more than 30 days agoNoNot surePrefer not to sayWhen is the best time to contact you to discuss an ongoing clinical trial for which you may be eligible to participate?Have you received Tepezza or any other treatments for your Thyroid Eye Disease?Please Select an optionPlease Select an optionNo TepezzaNot sureOther treatmentsSubmit
