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.

Authorized to Leave a Detailed Voice Mail?
Is this the Participant’s full-time residence?
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.)
If you have any questions about this form or how your answers will be used, please contact Ana Nunez, site contact for the study from Syrentis Clinical Research at (714) 542-3008.

Study Participant Medical History

Do You Have a Diagnosis of:
MM slash DD slash YYYY
Have you had memory decline with gradual onset and slow progression over the last 6 months?
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?
Are you able and willing to attend regular research study visits approximately every 4 weeks for approximately 2.5 years?

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

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