link to The Center for Neurologic Study Home Page
 
Home
News/Events
Clinical Trials
Papers/Essays
About CNS
Helping CNS
Links
Current Treatment Trials   |   Trial Registration Signup
 


Trial Registration Signup


Please fill out this form if you would like to register for future CNS clinical research trials.

NOTE: The Center for Neurologic Study will keep these registration forms completely confidential. They will only be reviewed by our staff.


Your email address

Phone number (Optional)

Year of birth (Optional)

Sex
Male
Female

Diagnosis Please check all that apply. Refer to Treatment Trials for specific information about current studies.
Alzheimer's Disease
Diabetic Neuropathy
other Neuropathy
Multiple Sclerosis
Amyotrophic Laterial Sclerosis
Epilepsy
Headaches (migraine)
Stroke
Other, please specify

Zip code  If living in the US.

Country  If outside the US.

Your first name (Optional)

Your last name (Optional)

Your mailing address & zip (Optional)

May we contact you?
no
yes

How would you prefer to be contacted?
email
phone
postal mail

Would you also like to receive periodic updates about CNS news and events including the CNS support group for patients and their families?
no
yes

Other Info (Optional)





The Center for Neurologic Study
© 2002 All rights reserved.
Comments about the site? Let us know.