For patients

See if You May Qualify for a Study

Complete this short form and a member of the ACRC research team may contact you about current or future study opportunities. Submitting this form does not guarantee eligibility or enrollment.

Your contact information

First name *

Last name *

Email address *

Mobile number *

Home number (optional)

Preferred contact method *

Best time to contact *

About you

Date of birth or age range *

e.g. 1965-04-12 or 45–55

Preferred location *

Mailing address

Street address *

Apartment, suite, unit (optional)

City *

State *

ZIP code *

Emergency contact information

Full name *

Relationship *

Mobile number *

Secondary contact information (optional)

If you provide a secondary contact, please include at least a name and phone number.

Full name

Relationship

Phone number

Your research interest

Study of interest

Conditions of interest

e.g. high cholesterol, diabetes, migraine

Current medications (optional)

Brief medical history (optional)

How did you hear about us?

Confidentiality & consent

Confidentiality statement

Your personal information will be kept strictly confidential and used solely for the purposes of this clinical trial. All data will be stored securely and accessed only by authorized personnel. By signing below, you consent to the collection and use of your contact information as described.

I agree that ACRC may contact me about current or future clinical research opportunities.

I acknowledge the confidentiality statement above and understand that submitting this form does not guarantee eligibility and does not create a physician-patient relationship.

Signature (type your full name) *

Typing your name acts as your electronic signature.

Date of acknowledgement

Required fields marked with *.