Thank you for your interest in our Alzheimer's Study.

Please complete the brief survey below so our team can review your information and follow up with next steps.

Are you interested in the Alzheimer's study for yourself or for a friend/loved one?

For Myself

For a friend/loved one

Please select only ONE response

Have you been diagnosed with Alzheimer's? *

Yes

Would you be interested in a free memory screen?

Are you willing to travel to the clinic for your appointments?

Would you be interested in free transportation if provided?

What is your relationship to the potential participant?

Would they be willing to travel to the clinic for their appointments?

Would they be interested in free transportation if provided?

Are they over the age of 55?

Yes

This information is for the Study Partner (friend, family, or caregiver) of the Potential Participant. NBCR will contact you directly to discuss the next steps.

Study Partner First Name *

Study Partner Last Name *

Study Partner Phone Number *

Study Partner Email *

NOTE: Please enter YOUR email in the next form to have confirmation and correspondence sent directly to you.

How would you prefer we contact you ? *

This information is for the Potential Participant:

First Name *

Last Name *

Phone *

Email *

If you are a caregiver, please use YOUR email here

City

Postal Code *

How would you prefer to be contacted?

Please select how you would like us to contact you

By checking this box, I consent to receive non-marketing text messages from Neuro-Behavioral Clinical Research about Alzheimer's. Message frequency varies, message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

By checking this box, I consent to receive marketing and promotional messages including special offers, discounts, new product updates among others, from Neuro-Behavioral Clinical Research at the phone number provided. Frequency may vary. Message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

Neuro-Behavioral Clinical Research

has conducted over
200 Clinical Trials