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Activation code*

This is a unique code that is used once during sign up. Activation codes are distributed by participating Centres of Porphyria Expertise. Activation codes have an expiry date. If your code does not work it may have expired. Investigators: Contact your Centre of Porphyria Expertise for a new code. Centres: contact us at epr@helse-bergen.no

Porphyria Centre ID *

This is a unique code assigned to each Centre of Porphyria Expertise. Investigators: Contact your Centre of Porphyria Expertise for your code. Centres: contact us at epr@helse-bergen.no

Your associated Porphyria Centre is located here

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Firstname*

MiddleName

Surname*

Professional role (tick all that apply)

porphyria specialist (physician)
genetic counsellor
researcher/ site coordinator
general practitioner/ primary care physician
gastroenterologist
haematologist
dermatologist
psychiatrist
neurologist
surgeon
other specialist
allied health professional/ nurse
other

Working place (please edit if different form the Porphyria Centre)

Institution*

Address

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country*

Phone number

Email address* (username)

Password*

Password confirmation*

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