Represent Your Community

FDA approved clinical trials are offered in your area to preserve memories by combating Alzheimer’s disease. With the help of ongoing research, we provide hope for today and solutions for tomorrow at no cost to participants or their families. Individuals with dementia, caregivers and healthy volunteers are all urgently needed to participate in clinical trials focused on modifying the course of memory illness. Start something unforgettable and enroll today for your chance to help cure Alzheimer’s disease!

Space is limited!

If completing the form for a loved one, please answer the questions below on their behalf.

First Name: *

Last Name: *

Email: *

Phone Number: *

Age: *

Date of Birth *

Have you been diagnosed with Alzheimer's disease? *

Yes

Do you have an immediate family member that has been diagnosed with Alzheimer's or any form of dementia? *

Mother

Father

Sibling

None

What age was that family member diagnosed? *

Under 75

Over 75

N/A

Are you on medication for Alzheimer's disease? (Ex. Aricept, Razadyne, Exelon, etc.) *

Yes

Have you had cancer? If yes, you may be asked for additional information during a follow up. *

Yes

Have you had a stroke or heart attack in the last 12 months? *

Yes

Have you had one or more seizures in the last six (6) months? *

Yes

Are you willing to come to our office and sign a medical records release form? *

Yes

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