The information you are providing here will only be used to match you or a loved one to a clinical research trial site in the potential participant’s area. The site staff will contact you to see if you or person you completed the form for would like to participate. Please note the information you enter will be kept private, except when ordered by law, and only accessible to our Clinical Research Partners and affiliates and applicable regulatory agencies. If you have any questions regarding the handling of the information you have provided to, or if you would like to make any changes, please contact us at