First Name *

Last Name *

Phone *

Email *

Have you been diagnosed with uncontrolled gout?

Are you at least 18 years or older?

Do you continuously experience gout flare-ups?

Date of birth

What is your current weight? *

What is your current height? *

Have you ever been a patient of Altoona Arthritis & Osteoporosis Center and/or Altoona Center for Clinical Research? *

Do you have a history of cancer? *

How did you hear about us? *

Is there any other information you would like to provide us for your request for enrollment?

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