Patient Request Form

ALS patients who wish to participate in future trials or be considered FOR New Biotic's Compassionate Use Program,, Please complete the form below.

All information Received will be strictly confidential and will not be used for any other purposes.

Patient's Name *
Patient's Name
Contact's Name (if different from patient)
Contact's Name (if different from patient)
What is the patient's age? *
Is the patient willing to sign a Medical Records Release Form releasing relevant medical history and diagnosis information? *
Is the patient willing to sign a Patient Consent and Waiver Form, consenting to the treatment (if chosen to participate), knowing RaphaLX™ is an investigational new drug and knowing all the risks associated with its use? *