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Forms for
Patients

 

We encourage our patients to download and complete the following forms, in the interest of expediting your in-office experience:

Download Medical-Records-Release.pdf
Download Patient-Medical-History.pdf
Download Research-Trials-Patient-Interest.pdf

The staff at The Center for Clinical Research offers the opportunity to patients to participate in research trials related to Pain Management. If you are interested in receiving information on current trials please email Jill ( ), Lisa ( ), or Charlotte ( ).  Our email submission form below is unavailable at this time.  We are sorry for the inconvenience. 

Name:
Date of Birth:
 (DD/MM/YYYY)
Phone Number:
(123-456-7890)
Address:
City:
State:
ZIP:
Email Address:

The Center for Clinical Research add the above information to their records and contact me either by phone and/or mail when research studies become available for the following type conditions and/or devices:

Check the boxes below that are of interest.

Interested:
 Condition:
Neuropathic Pain
Low Back Pain
RSD
Fibromyalgia
Post Herpetic Neuralgia (PHN)
Cancer Pain
Osteoarthritis
Rheumatoid Arthritis
Implanted Devices
Any Chronic Pain Trial

   

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