I want to report:

A problem that happened with a patient who was treated with Spark Therapeutics’ product. A problem with Spark Therapeutics’ product that has not been given to a patient.

Please provide us with YOUR contact information (person filling out this form). We will contact you only if we need additional information.

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Please provide at least one of the following:

* Does Spark Therapeutics have permission to contact the treating healthcare provider in case of additional questions?