Form – Kerwin Medical Center Form

SEE IF YOU MAY PREQUALIFY

Volunteering for a clinical research study may be the first step to learning about your brain health and addressing symptoms of early Alzheimer’s disease.

Find out in minutes if you might pre-qualify to participate in a research study for an investigational drug to treat Alzheimer’s disease by answering the questions below*.

None of the questions are mandatory and you do not have to answer any question(s) that you do not want to answer. Your answers will only be used to help decide if you may be eligible to participate in Alzheimer’s research.

Participant Name

Year of Birth

Race/Ethnicity

Phone Number

Authorized to Leave a Detailed Voice Mail?

Yes

Address

Street Address City State ZIP Code

Is this the Participant’s full-time residence?

Yes

If completing this form on behalf of someone else, please indicate your name and your relationship to the participant (i.e. spouse, adult child, etc.)

Name

First Last

Relationship

User Agreement

I agree.

By signing up, I agree to be contacted about clinical research studies by the company Kerwin Medical Center, its affiliates, or partners. Typical methods of contact include phone calls, text messages, pre-recorded messages, emails, automated technology or postal mail.

As we contact you, your electronic record will be updated accordingly with current relevant health information. This consent is not required to participate in a clinical research study.

The “Participant” is the person who enrolls in the clinical trial. The “Study Partner” is a family member/friend or other person who can help complete the form and possibly assist the Participant with clinical trial participation.

The “Study Partner” can assist the “Participant” by helping answer the following health history questions. Answering the medical history is not mandatory and your answers will only be used to help decide if you may be eligible to participate in Alzheimer’s research.

If you have any questions about this form or how your answers will be used, please contact Andrea Hester, site contact for the study from Kerwin Medical Center at (972) 433-9100.

Study Participant Medical History

Do You Have a Diagnosis of:

Alzheimer’s disease

Mild Cognitive Impairment

Dementia/Other Dementia

No diagnosis/Unknown

Date of Diagnosis (if known):

MM slash DD slash YYYY

Have you had memory decline with gradual onset and slow progression over the last 6 months?

Yes

Notes

Do you have someone who could be a research study partner and attend regular visits with you and spends/could spend at least 10 hours/week with you?

Yes

Notes

Are you able and willing to attend regular research study visits approximately every 4 weeks for approximately 2.5 years?

Yes

Notes

If this form is completed by the study participant, please check boxes below to submit:

Consent

I agree

By checking this box, I am willfully sharing this information with the research site and consent to their receipt. I authorize Kerwin Medical Center to contact me if I am eligible or not eligible to participate in a research study about Alzheimer’s disease.

Consent

I agree

By checking this box, I consent to contact from the research site. If I am not currently eligible for a research study, Kerwin Medical Center is authorized to contact me or my designee in the future for other related opportunities. This may include educational events, registries, or other activities that may be of interest to me.

If this form is completed by the study partner, please check boxes below to submit:

Consent

I agree

By checking this box, I authorize Kerwin Medical Center to contact me if the Participant is eligible or not eligible to participate in a research study about Alzheimer’s disease.

Consent

I agree

If the participant is not currently eligible for a research study, Kerwin Medical Center is authorized to contact me in the future for other related opportunities. This may include educational events, registries, or other activities that may be of interest to the participant.

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