The Ocean State Crohn’s & Colitis Area Registry (OSCCAR)

Enrollment Contact Form for Patients

(If you are a medical professional, please use this form instead.)

We are asking your permission to contact you to answer any questions you may have about participating in OSCCAR and the arrange a visit.

By filling out this form, you agree to allow a member of the study staff to contact you. Submitting this form does not obligate you to participate in the study and does not change or decrease the health care you usually receive.

Please answer the following questions. If you would prefer to print and fax or mail your information to us instead, you can also download a printable version of this form. We are delighted with your interest and look forward to speaking with you soon.

Please leave the following field blank.

When were you/was your child diagnosed:

Diagnosis:	Crohn's Disease	Ulcerative Colitis
Physician who diagnosed you or your child:

Patient's First Name:
Patient's Last Name:
Guardian's Name (if patient is a minor):

How would you like us to reach you?
Phone:		E-mail:

What times of day work best?
Morning	Afternoon	Evening

For more information, please call 401-444-4143 or e-mail osccar@lifespan.org.

More about OSCCAR

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