Become a Participant

If you are interested in becoming a participant, please fill out this form and we will get in touch with you shortly.

 

Privacy

Please be advised that if you complete the study pre-screening questionnaire, you will be asked to provide personal information, including age, geographic location, and your current medical condition.Your privacy will be protected and the information you provide will only be shared with those involved with the clinical research study if it is determined that you may be eligible to participate, unless you permit us to do so or except as required by law. Your information will not be sold to outside companies, nor will it be stored or collected without your direct consent. Read our full privacy policy here.

* indicates required field

First Name*

Last Name*

Phone Number*

Your Email*

Best time to be contacted

Age

Sex
 Male Female

How did you hear about us?

Do you currently have, or have you ever had any of the following?
 ADHD Alzheimer’s Disease Anxiety Disorder Bipolar Disorder Bulimia or Anorexia Nervosa Depression Essential Tremors Hot Flashes Obsessive Compulsive Disorder Post-Partum Depression PTSD Schizophrenia Other Psychiatric Disorder Uterine Fibroids Other Unsure None of these apply

-If other, please indicate below:

How long have you been experiencing these symptoms?

Have you taken or been treated with an investigational drug within the last 30 days?*
 Yes No Unsure

Are you currently taking any type of medication either over the counter or prescribed by a doctor?*
 Yes No

What medications are you currently taking?

Questions or Comments?

Comments are closed.