Registration Form
Clinical Trials Registry
Free Registration For Patients
The information you provide below will be forwarded to
Clinical Trials which specialize in the medical condition/illness you seek treatment

How to use this Form:
u Use one Registration Form per patient
u Type in the Form, on screen response, (fill out all applicable blanks).
u If you make a mistake, backspace and type again, or highlight the entire box and hit "Backspace".
u Press "TAB" to move between blank spaces. When finished, please click on "Send it in".

u PATIENT INFORMATION:
First Name  M.I.  Family Name 
Sex  Male  Female
Date Of Birth  Age Months Years
Area Code  Day Phone Number  Night Phone Number 
E.Mail Address 
Preferred Communication Language:
English   . Other:  Please Type Here 

u PAST EXPERIENCE WITH CLINICAL TRIALS:
Have you ever participated in a clinical trial?  Yes  No
If yes, please give the following information:
Participation Date  Name Of Clinical Trial 
Medical Condition or illness 
 
u Medical Condition/Illness you seek treatment:
Diagnosis 
How far are you willing to travel (miles)? 

Do You Smoke? Yes  No

Are you taking medications for a chronic or a continuing medical problem? 
The medications could be prescriptions drugs and or birth control medications, herbal supplements, vitamins... etc.
Yes  No
If yes, please type below the medical condition, names of medications and last date of use:
.

 

Date This Form was completed 

Race/Ethnicity (type X in applicable boxes):
.
White/Caucasian
Black/African-American
Asian/Asian-American/Pacific Islander
Hispanic/Latina
Native American/Alaska Native
Middle Eastern Descent
Other:  Please Type Here 

© 2006 Doctors Marketing Service

Welcome to
Consultants Institute
P.O. Box 748
Lake Forest, California 92609-0748
 

Back To HOME PAGE