Complete Our Pre-screener Questions
to See if You Qualify

All information is kept strictly confidential and HIPAA compliant.

We will contact you to let you know whether or not you qualify. If you do not qualify at this time, you can choose to be contacted again to notify you of new studies for which you may be eligible. If you are not the patient filling out this form, please put your own information and best contact so that we can get in touch you. 

Are you currently taking any of the following medications? Please select all that apply.
How long ago were you diagnosed with Alzheimer's?
Who is filling out this form today?

Thanks for submitting! We will get back to you soon to let you know if you qualify!