Patient Registry for Herpes Simplex Virus Patients

Patients living with Herpes Simplex virus can join the Herpes Cure Advocacy patient registry to be alerted of clinical trials for which they may be eligible. If you have HSV and would want to be notified of clinical studies for new treatments please fill out this form.

Patient information will not be bought, sold, or shared with 3rd parties.

To be notified of upcoming clinical trials please fill out the secure, encrypted form below.

Please enable JavaScript in your browser to complete this form.

Patient's name *

First

Last

Contact Email *

Contact Phone *

Date of birth *

Infection Type *

• HSV-1 Oral
• HSV-1 Genital
• HSV-2 Genital
• HSV-2 Oral
• HSV Type/Location Unknown
• Herpes Keratitis
• Neonatal Herpes

Gender ID *

• Male
• Female
• Transgender
• Non-binary

Years Diagnosed *<112345678910111213141516171819202122232425262728293031323334353637383940>40

Country *AfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustriaAzerbaijanBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCentral African RepublicChadChannel IslandsChileChinaColombiaComorosCongoCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicDR CongoEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFaeroe IslandsFinlandFranceFrench GuianaGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJordanKazakhstanKenyaKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMauritaniaMauritiusMayotteMexicoMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNepalNetherlandsNicaraguaNigerNigeriaNorth KoreaNorth MacedoniaNorwayOmanPakistanPanamaParaguayPeruPhilippinesPolandPortugalQatarRéunionRomaniaRussiaRwandaSaint HelenaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSan MarinoSao Tome & PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSomaliaSouth AfricaSouth KoreaSouth SudanSpainSri LankaState of PalestineSudanSurinameSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandThe BahamasTimor-LesteTogoTrinidad and TobagoTunisiaTurkeyTurkmenistanUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVenezuelaVietnamWestern SaharaYemenZambiaZimbabwe

Permission & Agreement *

• I agree and give my permission.

I agree and give my permission to enter my personal information into the Herpes Cure Advocacy Official Clinical Trial Registry. I agree and give my permission to be contacted for clinical trials for which I may be eligible.

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