PATIENT REGISTRATION

Boca Raton Clinical Research follows HIPAA Guidelines and maintains patient confidentiality. Patient registration, medical history, family history and trial participation is stored in our patient database and is never shared or sold

*PATIENT FIRST NAME
*PATIENT LAST NAME
*PATIENT YEAR OF BIRTH
*ZIP/POSTAL CODE


*CONTACT PHONE


EXTENSION (if applicable):
*May we leave a message:? Yes, leave a message No
If not the patient, to whom we speak:


ALTERNATE PHONE NUMBER
May we leave a message:? Yes, leave a message No
If not the patient, to whom we speak:
*Required fields


PLEASE INDICATE WHICH ARES INTEREST YOU:
Alzheimer’s disease
Anxiety disorders
Arthritis
Asthma
Bipolar disorder
Brain tumors
Cancer:
      Bladder
      Breast
      Colon/Rectal
      Kidney (renal cell)
      Leukemia
      Lung
      Melanoma
      Non-Hodgkin’s lymphoma
      Pancreatic
      Prostate
      Thyroid
Chronic obstructive pulmonary disease
     (COPD)
Cushing’s disease
Dementia
Depression
Diabetes
Eczema/Dermatitis
Emphysema
Epilepsy
Eye health
Fibromyalgia
Gastrointestinal disorders
Generalized anxiety disorder
Gout
Heart disease
Hepatitis
High Blood Pressure
HIV (AIDS)
Juvenile arthritis
Obsessive-Compulsive disorder
Osteoarthritis
Osteoporosis/bone health
Overactive bladder
Parkinson’s disease
Psoriasis
Rheumatoid arthritis
Schizophrenia
Thyroid disease
Ulcerative colitis
By clicking “submit” you give BRCR permission to forward your phone number and patient information to the study coordinator for the sole purpose of facilitating participation in this study and to follow up with you regarding qualification for this study. BRCR will not disclose this information to any other parties. For more on this, see our policy.

Thank you for your time today. We appreciate your interest in contributing to medical research and in participating in clinical study. Your information will never be sold and never shared without your permission, except as required by law. Would you like us to contact you with future information about studies?
YES NO, thank you


PATIENT REGISTRATION

Boca Raton Clinical Research follows HIPAA Guidelines and maintains patient confidentiality. Patient registration, medical history, family history and trial participation is stored in our patient database and is never shared or sold