Secure Patient Qualification Form

PLEASE NOTE THAT THIS FORM IS FOR DALLAS TEXAS ONLY!

For more locations please select one from this list: Houston, El Paso, Pennsylvania, Santa Ana, CA, New York

Secure Registration Form

 YES! Please sign me up for monthly newsletter emails - MUST CHECK YES IN ORDER TO SUBMIT THIS CONTACT REQUEST FORM. Alternatively, you may contact us directly at 972-4-DOCTOR for information about our studies.

Please fill out the form below to be added to our monthly email newsletter and be notified of new studies starting each month. We are privately owned and do not share information with any outside parties, and we do not bill for insurance. Your information is kept confidential. We will call to verify the information you submit on this form is accurate and to discuss our currently enrolling studies.

* Indicates a required field

First Name *
Last Name *
E-Mail

 

Address
City
State
ZIP

 

(You must fill out at least ONE phone number so we can verify this information.)

Home Phone
Work Phone
Cell Phone

 

Gender * Male     Female
(required - so we can notify you of appropriate studies)
Date of Birth *
(required - so we can notify you of appropriate studies)

 

How did you find out about our research clinic?
  Referral - Word of Mouth
  TV Guide Ad
  Dallas Morning Newspaper Ad
  Employment News
  Job Connection
  Dallas Observer
  Centerwatch
  Internet Search
  Health Fair
  Job Fair
  Flyer in school
  Flyer in doctor's office
  Radio Ad
  TV Ad
  College Paper/College Campus
  Clinical Connections
  Other

 

Studies of interest (optional)- please check the studies you would like to be notified of
* To pick more than one study hold down your Ctrl key and left mouse click.

Medical Studies

Other:
 
Men's Studies

Other:

 

Women's Studies

Other:
 
Psychiatric Studies

Other:

 

Addiction Studies

Other:
 
Pediatric Studies

Other:

 

Skin Studies

Other:

 

SKINTASTIC is our PARTNER FOR MEDICAL SKIN REJUVENATION (NOT STUDY-RELATED - OFFICE VISITS REQUIRE PAYMENT FOR SERVICES RENDERED) - optional
I would like to be contacted by SKINTASTIC in Plano or Dallas for an appointment to discuss a skincare regimen for me! SKINTASTIC specializes in state-of -the art skin solutions and wrinkle reduction like BOTOX Cosmetic, Restylane, Fotofacial and Microdermabrasion. THIS IS NOT STUDY-RELATED. OFFICE VISITS REQUIRE PAYMENT FOR SERVICES RENDERED. For more information, visit www.skintastic.com or call 972-620-FACE.
 
Allergies? Yes! Please contact me to schedule an appointment to discuss allergy testing and treatments. This is not study related. Office visits require payment for services rendered. Dr. Jeffery Adelglass, ENT, offers immunotherapy for allergy relief, pollen count information and sinus surgery for your healthcare needs. For more information, visit www.entdocs.com.

NOTE: By completing and submitting this Form to us, we will better be able to Pre-Screen you for new Studies as we receive them. Your name will then automatically be placed on a List to be called for that study. All information is confidential! Please go to our Privacy Policy for more information.