GLIA-CTN Online Referral Survey

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Thank you for your interest in the Global Leukodystrophy Initiaitve Clinical Trials Network (GLIA-CTN). Our brief Online Referral Survey is intended to collect basic demographic and contact information, as well as additional details that will allow our team to identify the most appropriate clinical and/or research opportunities available to you through our network.

Your responses will allow our coordinators to deliver prompt and personalized attention, and they will be kept strictly confidential. Once you have complete and submitted the form, a coordinator will review your responses and arrange a time to introduce the program more formally.

Please note that you must complete all pages and hit the "Submit" button in order for our staff to be notified. Thank you!

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You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.