Registry for People with Long COVID

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Thank you for your interest in the Long COVID registry! If you agree to participate, you will hear about research related to Long COVID for which you may qualify.

To learn more about Long COVID, also known as long haul or Post COVID-19, please go to the WHO website: https://www.who.int/publications/i/item/WHO-2019-nCoV-Post_COVID-19_condition-Clinical_case_definition-2021.1

Please, read the document below. You will then be asked to sign and add your contact information

To keep a copy of the Informed Consent for your own record or to read it from your own device, please click on the attachement below to download the PDF document.

Attachment:Informed Consent Form - UF Long COVID Registry.pdf

Please, sign and enter your information below to be in the registry

Do you agree to participate in the study?

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Yes

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M-D-Y

Your First Name:

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Your Last Name:

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Gender:

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Date of Birth:

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Age at Consent

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We're sorry, you don't qualify for this registry. The age range is 18-80 years old at this moment.

You can email Lydia Pezzullo, Clinical Research Coordinator, at lpezzullo@ufl.edu with any questions.

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City:

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Please click on the link to the right to add your signature.

Use your computer mouse, or finger if on a touchscreen, to draw your signature.

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If you would like to receive a copy of your signed Informed Consent by email, please enter your email address here:

If you would like to confirm your enrollment in the registry, please review the following page and certify that your information is correct.

If you do not wish to enroll, you may close this window at any time.

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.