Get Paper Application - Undiagnosed Diseases Network

Filling out the Paper Application for the Undiagnosed Diseases Network is a critical step in seeking diagnosis and care for undiagnosed medical conditions. This guide provides clear instructions to help you navigate each section of the application with confidence and ease.

Follow the steps to complete your application accurately.

1. Press the ‘Get Form’ button to access and open the Paper Application - Undiagnosed Diseases Network document.
2. Begin by identifying yourself as either the applicant or the legal guardian of the applicant. Select the appropriate option and provide your name and relation to the applicant.
3. Read and acknowledge the consent form carefully. Make sure to understand that participation is voluntary and discuss any personal beliefs that may affect participation.
4. Provide identification details. Fill in the patient or guardian's email address, the patient's name, address, and phone number. Include the parent or guardian's name if applicable.
5. Complete the patient information section, including the date of birth, gender, race, and ethnicity. Ensure you answer all required questions accurately.
6. Indicate the applicant's primary symptoms by selecting the category that best describes them from the list provided.
7. Provide details about the onset of symptoms, family history of similar symptoms, and any environmental exposures related to the illness.
8. If applicable, disclose if the applicant is currently involved in other clinical trials or has been seen at a UDN clinical site before. Indicate travel limitations if any.
9. Fill out the healthcare provider information section with their email, name, address, phone number, and fax number.
10. Attach a summary letter from your referring licensed healthcare provider. Ensure it is on official letterhead and signed.
11. Review the completed application for accuracy. Once satisfied, save the changes, download, and print your form if needed.

Take the next step towards diagnosis and complete your application online.