Join our e-list:

By joining the e-list CCRS will periodically send you e-mail updates about upcoming studies and CCRS events.

>> click here for details

 

Study Interest Form

Before completing the interest form below please review the CCRS HIPAA Statement of Privacy included here to ensure your understanding that all the information you are submitting is protected and kept private. It will not be sold or distributed in any way and is only used internally to treat you, or your minor child, as a potential candidate for study participation. Also, please note that fields marked with * are required.

>> Read the CCRS HIPAA Statement of Privacy.

 

Have you read the CCRS HIPAA Statement of Privacy?

Yes
No

 

Do you understand and agree to allow the staff of CCRS to contact you?

Yes
No

*If no, please e-mail us any questions or concerns you may have so a staff member can contact you directly; or simply do not complete the form below.

 

May we keep your information on file to contact you for studies you may qualify for?

Yes
Undecided
No

 

* First Name
* Last Name
Parent's Name

(Required for Participants under age 18, also include daytime/mobile telephone numbers)

 

Street Address
City
State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code
Occupation
Daytime Phone
Home Phone
Mobile Phone
* Email
Date of Birth (day/month/year)

 

What Studies are you interested in?

Allergies
Arthritis
Asthma
Diabetes
Eczema
High Blood Pressure
High Cholesterol
Insomnia
Weight Loss

Are there other conditions that interest to you or your family?

 

Gender Please Select Male Female
Height
Weight
Race Please Select Cauc/White African American Hispanic Asian Native American Multi-racial (Some clinical studies are race specific)
Do you smoke? Please Select Never Currently Quit
Do you drink? Please Select Yes No Occasionally
Are you allergic to any kind of medication?

 

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