Register or sign-in as a physician or other professional

A unique Identification number will be created for the case you are submitting to the registry. Submit each case for a patient only once.

Obtain Submission Packet.
After you register, receive a case number and submit case information, we will mail you a submission packet containing the forms and sample collection materials.

OR, if urgent sample collection is necessary, download our Submission Kit for instructions.

Put the case number on the Consent Form and present it to the patient.

NOTE: An AzCERT staff member must obtain patient consent in addition to the signed consent form. A phone call is best, but e-mail may be an acceptable method to obtain consent in some circumstances. The Western Institutional Review Board (WIRB) requires that all who obtain consent must have completed training in Protection of Human Subjects.

Obtain samples: buccal swab and/or blood sample on filter paper.

Complete: the Registry Submission Form.

Prepare your submission package.
All items should be labeled with the unique Case Number that was assigned when you registered and created a case.

You should return to us:

• Completed Registration Submission Form
• Original signed and dated consent form (patient keeps one copy for his/her records).
• Blood sample on filter paper, or, if blood sample is not possible, buccal swab on filter paper (or both).
• 12 lead ECG (hard copy and electronic format if possible). Please include ECG taken before the patient was given suspect drug, while taking the drug and after stopping the drug if at all possible.
• Rhythm strips for arrhythmia documentation if available