Patient Questionnaire

Fill out our questionnaire below to join our database of patients and see if you qualify for any current or future studies.

Preferred Method(s) of Contact
We ask for this information because some of our studies have sex-specific inclusion or exclusion criteria.
Most of our studies require patients to be 18 or older, though we do have some pediatric studies. If you are younger than 18, please ask a parent or guardian to submit this form on your behalf. 
Best Time(s) to Contact You
Please select all that apply. We will do our best to contact you within the times you specify.
Study Interests: Neurology

Please select all of the trial research areas you are interested in learning more about. 
Study Interests: Internal Medicine

Please select all of the trial research areas you are interested in learning more about. 
Study Interests: Cardiology
Please select all of the trial research areas you are interested in learning more about. 
Study Interests: Rheumatology
Please select all of the trial research areas you are interested in learning more about. 
Study Interests: Dermatology/Trichology
Please select all of the trial research areas you are interested in learning more about. 

We want to add you to our clinic database so we can contact you about upcoming studies that you may benefit from. Do you consent to be added to our contacts database for this purpose? You can opt-out at any time.


Privacy Statement: Your information will remain strictly confidential. Clinical Investigation Specialists, Inc. will not sell or distribute your data, and will operate in compliance with Health Insurance Portability and Accountability Act of 1996 (HIPAA) patient privacy regulations.