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Inquire Today for a FREE Clinical Trial Evaluation! (Phone Screener)

If you are human, leave this field blank.

First Name *

Last Name *

Phone Number *

Email Address *

Home Address

Are you calling for yourself? *

If NO, who are you calling for? *

What prompted you to contact us today?

What age are you or is the person you are contacting us about? *

Date of birth *

Have you been diagnosed with a memory disorder?

What is the diagnosis? *

Who diagnosed you? *

Are you taking any medications for this diagnosis? *

Please list medication names/date started *

Do you know your MMSE score? *

What is your MMSE score? *

Are you currently participating in any other clinical trials? *

Have you ever participated in clinical trials? *

Do you have a pacemaker? *

Have you ever had a stroke? *

Have you ever been diagnosed with any type of cancer? *

When was the diagnosis made? *

How long have you been in remission? *

What type of cancer? *

Do you have any other neurological disorders? *

If you have any other neurological disorders, please list them here: *

Do you take any anti-depressants? *

If you take anti-depressants, please list them here: *

Do you have a caregiver/study partner available for visits? *

Do you plan to travel for long periods of time in the near future? *

Have you had an MRI/CT/PET scan in the past 12 months? *

Do you have any questions or comments? Please note them here:

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