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Become a participant
You are only one. But you have the power to heal someone, provide hope, change a life, and yours at the same time. Thank you for your interest in becoming a clinical trial participant at MARC! Complete the below form to be alerted when studies of your choice become available. Experience the power of one today!
This form will be used by the MARC staff only, in assisting with pre-screening for new and current studies. This information will not be shared with third party vendors.
Required fields shown in blue.
| First Name |
Last Name |
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| Email Address |
Gender Male Female |
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| Primary Phone Number |
Alternate Phone |
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| Address |
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| Address (line 2) |
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| Birth Date (mm/dd/yy) |
Race |
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| Height feet inches |
Weight lbs |
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| Do you use tobacco? Yes No |
Year quit |
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| Please list any chronic medical conditions (such as High Blood Pressure, Diabetes, Depression, etc.) |
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| Please list any medications you take regularly (over the counter and prescription) |
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| Please list any medication or food allergies |
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| Are you interested in a particular study? |
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| How did you hear about us? |
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| Questions or Comments |
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