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How to Enroll in the CMT North American Database

There are a few forms to fill out to be entered into the database. All of the forms that are needed to enroll can be downloaded from this site. DO NOT send the forms to us electronically. Please download them and mail them to us.

IF YOU ARE THE FIRST PERSON IN YOUR FAMILY TO ENROLL IN THE DATABASE, please fill out all of the following forms. (You will need Adobe Acrobat Reader to open these forms. Click here to get the free software if you don't have it.) The family history questionnaire (FHQ). Even if you are the only person affected in your family or if you do not know any information about your family, please fill out the form to the best of your ability. Questionnaire about symptoms. Physician examination form. This is to be filled out by the physician most familiar with your condition. Please download the physician Cover Letter that explains the database and give it to your physician. Consent form to allow your information to be entered into the database. Consent form to release medical records to the CMT database researchers. Please be sure to include the name of the hospital or clinic where your physician(s) practice. Consent form so that we may use your protected health information (PHI) for research purposes. Send the ALL of the forms together to the address listed below. Please do not send forms individually. When we receive this information we will contact you if we have any questions. Otherwise we will then put together a list of all of your family members who you have indicated are affected. We will send you this list and ask for contact information on these people as well as permission to contact them. IF THE PERSON TO BE ENROLLED IS BETWEEN THE AGES OF 13-17: In place of the consent form that allows your information to be entered into the database: The person between 13 and 17 must read and sign the assent form to have their information entered in the database. A parent or guardian must sign this form to allow their child's information to be entered in the database. IF THE PERSON TO BE ENROLLED IS A CHILD UNDER THE AGE OF 13: In place of the consent form that allows your information to be entered into the database: A parent or guardian must sign this form to allow their child's information to be entered in the database.

IF YOU HAVE ANOTHER FAMILY MEMBER ALREADY ENROLLED IN THE DATABASE, please fill out all of the forms listed above EXCEPT the family history questionnaire and send them to the address listed below. If you are not sure if other family members are in the database OR if you have very distant relatives in the database, please fill out all of the forms. Please call or email Kevin Francies, Research Assistant, for the CMT Database, at (313) 577-5273 if you have questions. Thank you for your support of the CMT North American Database! IF YOU ARE NOT COMING TO THE WAYNE STATE CMT CLINIC ALL FORMS SHOULD BE MAILED TO: Kevin Francies The CMT North American Database Elliman Bldg. Rm. 3206 421 E. Canfield Ave. Detroit, MI 48201 IF YOU ARE COMING TO THE WAYNE STATE CMT CLINIC AND JOINING THE DATABASE PLEASE SEND YOUR FORMS (ALONG WITH ANY OTHER CLINIC FORMS) TO: Lisa Rowe Elliman Bldg. Rm. 3301 421 E. Canfield Ave. Detroit, MI 48201