See if You Qualify - Clinical Enrollment

Are you answering this screening questionnaire for yourself, or a loved one?

Myself
A loved one

What is your loved one's full name (first and last)?

Are you between 50 and 80 years old?

Yes
No

Is your loved one between 50 and 80 years old?

Yes
No

Do you have a confirmed diagnosis of—or are suspected to have—Alzheimer’s disease, dementia or mild cognitive impairment (MCI)?

Suspected memory impairment
Diagnosed
No

Does your loved one have a confirmed diagnosis of—or is suspected to have—Alzheimer’s disease, dementia or mild cognitive impairment (MCI)?

Suspected memory impairment
Diagnosed
No

Do you have a caregiver who would be willing to act as your study partner and attend all scheduled visits with you for the duration of a clinical trial?

Yes
No

Does your loved one have a caregiver who would be willing to act as their study partner and attend all scheduled visits with them for the duration of a clinical trial?

Yes
No

First Name

Last Name

What is your email address?

What is your phone number?

Where are you located? (City, State)

Do you have another disease/condition that you would be interested in getting treated through other trials?

What disease/condition are you interested in?

Which race or ethnicity best describes you?

Which race or ethnicity best describes your loved one?

Multiple ethnicity/ Other (please specify)

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