Charak Clinical Research Center Eligibility Form

A member of our staff will contact you if they feel that you may be a good candidate for a current or future study.

Please correct the errors described below.

Charak Clinical Research Center

research@charakcenter.com

(216) 559-1360

Full Name

First Name

Last Name

Phone Number

Age

Address

City

State

Zip Code

Please check the clinical trials or current conditions that would be of interest to you: Check all that apply

Leave Blank

Alzheimer's Disease

Depression

Bipolar Depression

Bipolar Disorder

Schizophrenia

Transcranial Magnetic Stimulation (TMS)

Vagus Nerve Stimulation (VNS)

PTSD

OCD

Substance Use Disorders (SUDs) / Addictions

Other

Are you currently taking any prescribed medication for the condition you selected above?

Yes No

Please list medication(s) (Optional)

Please list any additional Medical History that may be relevant (Optional)

Your information will be encrypted.

Charak Clinical Research Center

research@charakcenter.com

(216) 559-1360

The Charak Clinical Research Center

A Quest for Cures

www.charakcenter.com/research

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