Research Across America Banner

PLEASE NOTE THAT THIS FORM IS FOR EL PASO TEXAS ONLY!

 

 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 1-877-STUDIES (Study Line) 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.

First Name (required)


Last Name (required)


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


Sex
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
  El Paso Times
  Internet Search
  Event
  Flyer
  Radio Ad
  TV Ad
  Craigslist
  Health Fair
  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:  


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.



 


Employment Opportunities

 

All human images on this website are models, unless otherwise indicated.
Copyright © 2011, Research Across America. All rights reserved.