Pacific Northwest Multiple Sclerosis Registry

(formerly known as Oregon MS Registry)

Please complete the form below so that we may add you to the Pacific Northwest Multiple Sclerosis Registry. We will mail you a short, anonymous survey within one week after you join the registry.

Learn more about how the Pacific Northwest Multiple Sclerosis Registry project will benefit research to improve MS care in this region.

(Fields marked with * are required)

Please fill in the following information

First name: *
Middle name:
Last name: *
Street: *
Apartment #:
City: *
State: *
ZIP code: *
Date of Birth: *
Gender: *	Male Female
Ethnicity: *	Hispanic or Latino Non-Hispanic or Latino
Race: *	(Please select one or more that you consider yourself to be) American Indian or Alaska Native Asian Black or African-American Native Hawaiian or Other Pacific Islander White
E-mail address:	We will only use this address to send you e-mails directly related to the MS Registry project. We will not share your e-mail address with any third parties.
Last 4 digits of Social Security Number:	This information will only be used to help us verify if you have already signed up in the past.
Are you a client of the National MS Society? Yes No
If not, would you like to receive resource information from the Oregon Chapter of the National MS Society? Yes No
By submitting the above information, you are consenting to participate in the Pacific Northwest Multiple Sclerosis Registry.