MyIBD.org - IBD Updates

IBD Updates Registration Form

* required fields

First Name*

Last Name*

Email*

Address

City & State

Postal Code*

Phone

( ) -

Year of Birth*

Sex

Male Female

State of Health

Remission (disease not active)
Flare-Up (disease active)

	I would like to receive additional information about Inflammatory Bowel Disease products and/or services

	Please keep me informed of future programs and content on the MyIBD Web site

Please choose the statement that best describes you.

What condition have you been diagnosed with?

What medication are you current taking?

Aminosaliicylates

Immunomodulators and Immunosuppresives

Corticosteroids

TNF-Alpha Inhibitors

Antibiotics

Over the Counter
Other
Not currently on medications

This site has been underwritten thanks to unrestricted educational grants
from Abbott Laboratories, Procter & Gamble Pharmaceuticals,
Salix Pharmaceuticals, Inc., and Shire USA Pharmaceuticals Inc.