Arthritis Trial Contribution Form
If you wish to contribute offline, you can
print this form and fax to +64 4 4769088 or mail it back:

Dr G Chiu
Karori Mall
Karori, Wellington
New Zealand

However, I would still appreciate your filling in and submitting this form so that I can capture your data electronically. In this case, just put in the credit card number "coming by mail" or whatever! You still need to provide a valid expiry date though ie. after today. This also applies if sending a check or other form of payment.

I can accept Visa, Mastercard, Amex

To contribute, complete the form below then click on "Make contribution".
Proposal: A prospective observational internet based self report study of inflammatory arthritis and allied conditions.

Benefits: to allow one to chart one's own progress, and to show others starting similar medication what to expect ( progress, flares, side effects etc). The data could also be used for other purposes when those purposes become clear!

Entry criteria:

  1. Cost: a contribution of at least US$10/year (US$20/2 years)
    • to cover costs of programming
    • administration
    • server time and traffic
    • dissuade vandalism ( deliberate sabotage by entering false data)
  2. Expression of interest without committment.
  3. Must have a rheumatic disorder ( includes fibromyalgia and chronic fatigue syndrome )
  4. Can be on any anti-rheumatic drug or none
  5. If not on anti-rheumatic drug, then should be about to start something ( preferably antibiotics ) within the next year.
  6. Agree that the data may be used by Dr G Chiu for subsequent publication in a reputable medical journal
  7. Requires a Java enabled web browser (to see the graphs which are in the form of Java applets ). Java not required to enter data but javascript a big plus. Note that Internet Explorer/Netscape 3 and above are okay in both of these regards.
  8. Accept that this project to take about a month or more from the time we get enough names. 



Personal Information:


            Name: 

         Address: 

         Address: 

            City: 

           State:           Zip/Area Code: 

         Country: 

           Phone: --       Fax: --          

 Internet E-Mail: 

         User ID:  to access your own data - make one up

 	Password:  of 5-10 characters. Make one up that you can remember!!







Credit Card Info





Amount you are contributing: US$ 


    Credit Card Number: 

    Expiration Month:   Year: 

        Name on Card: 

Name of Issuing Bank: 

           Card Type:

Write any comments or special instructions here:

NB: To save me replying to every single contribution, I have set up a contributors list of those ones that I receive. If your name does not appear within a week, try sending the form again!!

NB: Your credit card will not be charged until we go online with the study!