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Patient
Log
To
assure patient confidentiality, patient identifiers are not
collected by the Registry, rather the Registry assigns a number.
The Patient Log is a suggested means to link the Registry ID with the
provider’s identification for patients enrolled in the
Registry.
(This form is NEVER returned to the Registry.)
 Click
here to download the Patient Log Form.
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Registration
Form
Collects
minimal demographic information and disease status information.
Call
or fax the Registry to obtain a Registry ID number.
Complete
the 1-page Registration Form and relevant information on the
Antiretroviral Therapy During Pregnancy Form and
Mail,
fax, or call the Registry to provide the information.
Click
here to download the Registration Form and Antiretroviral Therapy
During Pregnancy Form.
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Antiretroviral
Therapy During Pregnancy Form
Collects
information on antiretroviral exposures during pregnancy.
Complete
the exposure information for therapies to-date during the current
pregnancy.
A
copy of this form will be returned for update at the time of
outcome of pregnancy.
Click
here to download the Antiretroviral Therapy During Pregnancy Form.
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Follow-up
Form
Collects
information on the outcome of pregnancy and description of any
birth defects identified.
The
Registry will send this Follow-Up Form with a copy of the
Antiretroviral Therapy During Pregnancy Form to be updated with
exposure information since Registration.
Complete
both forms and
Mail,
fax, or call
the Registry to provide the information.
Click
here to download the Follow-up Form.
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Targeted
Follow-up Form
If
a defect is noted
additional information related to the defect will be requested.
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