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*First Name

*Last Name


*Gender
Male
Female

*Date of Birth



*E-mail Address

*Confirm E-mail Address


*Street Address

Street Address 2

*City

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*ZIP



*1a. What condition(s) have you been diagnosed with?
Crohn's disease
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1b. When were you diagnosed (mo/year)?  


2. Which, if any, of the following medications have you taken in the past or are you currently taking to treat your Crohn's disease? (Check all that apply.)
  Previously Currently

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3. How often do you experience Crohn's disease symptoms?

4. How likely are you to talk to your gastroenterologist about a different treatment for your Crohn's disease?
   If so, when? (mo/year)


5. Would you be willing to participate in a market research study?

6. Which best describes you?

For US residents only.

I understand that the information I've provided will be used only by AbbVie and its contracted third parties to mail, e-mail, and phone me with helpful information on my condition and AbbVie treatments, products, and services, and for marketing and informational purposes. To be removed from our mailing list or request a copy of this information, contact: 1.888.857.0634.


*First Name

*Last Name


*Gender
Male
Female

*Date of Birth



*E-mail Address

*Confirm E-mail Address


*Street Address

Street Address 2

*City

*State

*ZIP



*1a. What condition(s) have you been diagnosed with?
Ulcerative colitis
Unsure

1b. When were you diagnosed (mo/year)?  


2. Which, if any, of the following medications have you taken in the past or are you currently taking to treat your ulcerative colitis? (Check all that apply.)
  Previously Currently

All trademarks are properties of their respective companies.


3. How often do you experience UC symptoms?

4. How likely are you to talk to your gastroenterologist about a different treatment for your UC?
   If so, when? (mo/year)


5. Would you be willing to participate in a market research study?

6. Which best describes you?

For US residents only.

I understand that the information I've provided will be used only by AbbVie and its contracted third parties to mail, e-mail, and phone me with helpful information on my condition and AbbVie treatments, products, and services, and for marketing and informational purposes. To be removed from our mailing list or request a copy of this information, contact: 1.888.857.0634.