Abraham Research Participants

Contact Us

Abraham Research, PLLC.

2300 Chamber Center Drive, Suite 102

Fort Mitchell, Kentucky 41017

Phone: 859-371-3797

Fax: 859-371-3799

Email: info@abrahamresearch.com

 

Click here for directions

 

CLINICAL TRIALS - SIGN-UP FORM

To determine if you qualify for a research study, we will ask you some questions about your medical history and present condition. This survey will remain confidential and will be reviewed by the research staff only. This information is for pre-screening purposes only and does not guarantee qualification for a study. It may be kept on file for future studies for which you may be eligible. If you do not qualify for a study or choose not to participate, at your request we will destroy the information submitted in this survey.

Do you permit Abraham Research to retain the information you submit on this form on file for future studies for which you may be eligible?
	Yes   |   No
Patient Information	*required field
*First Name	*
*Last Name	*
Date of Birth	MONTH JANUARY FEBRUARY MARCH APRIL MAY JUNE JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER DAY 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 YEAR 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923
*Sex	MALE FEMALE *
*Home Phone	*
Alternate Phone
Email Address
*Street Address	*
*City	*
*State	*
*Zip Code	*
Clinical Trial Interest	Allergies Allergic Rhinitis Asthma COPD Hay Fever Hives, Chronic Urticaria, Chronic Diabetes Other
Where Did You Hear About Us?	Print Ad Local Sign / Banner TV / Cable Radio Friend Internet Other