Providence Brain and Spine Institute – Clinical Trials Patient Interest Form
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Providence Brain and Spine Institute - Clinical Trials Patient Interest Form
The purpose of this form is to obtain information from patients who are interested in participating in a clinical trial at the Providence Brain & Spine Institute. By completing and submitting this form, you are requesting the research staff to review your health information and assess your eligibility for potential clinical trial participation.
*
required for submission
Name of person completing this form
*
Patient Name
*
Age
Contact phone
*
Email
How did you hear about us?
-- None --
Neurologist
Primary Care Physician
Outside Referral
Internet Search
clinicaltrials.gov
Providence Brain & Spine Institute Website
Friend
Family
Other
Clinical trial disease of interest
*
ALS (Amyotrophic Lateral Sclerosis)
MS (Multiple Sclerosis)
Dementia
Stroke
Epilepsy
Headache
Brain Tumor
Parkinson's Disease
Other, please specify
By selecting "Yes," I agree to the
Providence Health & Services Notice of Privacy Practices
and wish to proceed
*
Yes
Once completed and submitted, the information on this form will be securely sent to the Providence Brain and Spine Institute Research Department. You will be contacted within 3-5 business days.
For additional information regarding your personal and health information and how that information may be used and disclosed by Providence Health & Services, please see our
Notice of Privacy Practices
.