Site application · PPRN-001-2025

Apply as a registry site.

One form, about four minutes. Licensed clinicians only. No cost. No patient information is collected here.

Please fix the highlighted fields.

Have an email signature? Paste it and we'll fill the form

Paste your signature block (name, credential, clinic, address, NPI, email, phone). We fill what we can find; you check every field. We never fill in your signature.

Signature block

Principal investigator

Full legal name

Credential

State of licensure

State license numberUsed only to verify licensure.

NPI10 digits. We check it against the NPI check digit.

Site

Clinic or practice name

Street address

City

State

ZIP

EMR in use

Work emailYour site code and access key are sent here.

Phone

Consent and signature

Site Participant Consent, version 2.0 · effective September 15, 2026. You agree to report serious adverse events within 7 calendar days and others within 5 business days, submit de-identified data within 14 days of each visit, keep identifiers at your clinic, and retain records for 7 years. Participation is voluntary; sourcing is your choice. Read the full consent (opens in a new tab).

Fingerprint 2aa45ade605c7aeb49d1df4ddb3ddfa31c107a8e5af23e73f7558cee4db4af2c

I have read Site Participant Consent version 2.0 and agree to its terms on behalf of the site named above.

Type your full legal name to signTyping your name here is your electronic signature. It is recorded with the date, time and consent fingerprint.

Signed record

Application received.

We verify your license and NPI and email your site code, access key and the patient data-collection consent within two business days. Save or print this page as your copy of what you signed.

View the consent you signed