Your decision to complete N.E.C.C.R.'s online screening questionnaire is voluntary. You must be at least 18 years of age to participate in a clinical trial. 

Please keep in mind that any information provided in the form is not confidential to N.E.C.C.R. as it may be shared with research centers to help identify a clinical trial for you.

First:   Middle:   Last:   

 

Address:

City: State:    Zip:

 

Home Phone:    Work Phone:

E-mail: Age:   Gender:

 

Please check off the following studies you would be interested in:

  Allergies   Diabetes   Obesity
  Angina   Diabetic Foot Ulcers   Pneumonia
  Anxiety   Heartburn   Reflux
  Arthritis   High Cholesterol   Sexual Dysfunction
  Birth Control   High Blood Pressure

  Sinus Infections
  Bronchitis   Hormone Repl. Therapy   Skin Infection
  Chronic Pain   Influenza   Urinary Tract Infection
  Coronary Artery Disease   Migraine Headache   Yeast Infections
  Depression   Osteoporosis

other

 

 
 

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