Submission Form
Home Research Prevention Registry
Bryan ADRC Alzheimer's Disease Prevention Registry
Enrollment Form

(*) Required Fields


First Name:
* Last Name:
Gender:
* Preferred contact method?

Street Address:
City:
State:
Zip:
Home Phone: 123-456-7890
Cell Phone/Other: 123-456-7890
Email Address:
* What is your age?
 
For reporting purposes, please identify your racial/ethnic background. (You may check more than one)
 
How did you hear about the Registry?
 
I'm interested in being considered and contacted about the following future AD prevention studies:
 
* Submission Code:   
 


Risks: The Bryan ADRC prevention registry does not pose any known risks to you and we hope you may find it interesting and rewarding to be a member. Every effort will be made to maintain your privacy, however this cannot be completely guaranteed. We will assign you a unique ID number and the key code will be kept on a secured password protected computer separate from the information collected from this form.

Benefits: Personal benefit may not result from taking part in this registry, but prevention-related knowledge gained or treatments developed that will benefit others in the future.