Patient Questionnaire

Fill out our questionnaire below to join our database of patients and see if you qualify for any current or future studies.

We ask for this information because some of our studies have sex-specific inclusion or exclusion criteria.
Most of our studies require patients to be 18 or older, though we do have some pediatric studies. If you are younger than 18, please ask a parent or guardian to submit this form on your behalf. 

Contact Information

Preferred Method(s) of Contact
What is the best way to reach you? Select all that apply.
Best Time(s) to Contact You
Please select all that apply. We will do our best to contact you within the times you specify.

Study Interests

Please select all clinical trials you want to learn more about.
INTERNAL MEDICINE
Internal medicine is a specialty concerned with chronic and complex illnesses affecting the internal organs. Learn more about internal medicine here. 
RHEUMATOLOGY
Rheumatology is a specialty concerned with chronic illnesses affecting the joints, muscles, and connective tissues. Learn more about rheumatology here.
CARDIOLOGY
Cardiology is a specialty concerned with chronic illnesses affecting the heart and blood vessels. Learn more about cardiology here.
NEUROLOGY
Neurology is the branch of medicine focused on disorders of the nervous system, including the brain, spinal cord, and nerves. Learn more about neurology.
DERMATOLOGY
Dermatology is a specialty which focuses on skin, hair, nails and chronic illnesses which affect them. Learn more about dermatology here.

Privacy Statement: Your information will remain strictly confidential. Clinical Investigation Specialists, Inc. will not sell or distribute your data, and will operate in compliance with Health Insurance Portability and Accountability Act of 1996 (HIPAA) patient privacy regulations. 

We want to add you to our clinic database so we can contact you about upcoming studies that you may benefit from. Do you consent to be added to our contacts database for this purpose? You can opt-out at any time.