If you would like to find out if you qualify for one of our current studies, please submit your information below.
Potential Patient Form
After Form is Submitted
Once the submission is received you will be contacted by one of our experienced research coordinators within 2 business days to discuss study options and to schedule a complimentary consultation to evaluate your symptoms. We will not share or sell this information. We look forward to speaking with you!
The following is a list of forms we will ask you to complete the first time you come to the office. You may print and complete them in advance if you prefer and our staff will review them with you during the appointment.
Some email providers may place emails from Northwest Research Center in junk folders. To prevent this, make sure you add us to your safe sender list. By submitting your information, you consent to be contacted by a member of our staff now or in the future.
Per the federal Health Insurance Portability and Accountability Act (HIPAA), all individually identifiable health information that is provided to Northwest Research Center (NWRC) in the course of submission, evaluation, assessment, and treatment is considered “Protected Health Information” (PHI). This information includes demographics and relates to your past, present, and future physical and/or mental health or condition and related health care services. NWRC will maintain all information in a confidential and secure manner, ensuring that only authorized personnel will have access to your PHI. Unless required by state or federal law, NWRC will not release or disclose your PHI without your prior written authorization. You are permitted to review and request copies of the PHI, as well as withdraw the authorization for NWRC’s use of the information, at any time. Your PHI will be used to evaluate your potential for participation in our clinical research studies. If you believe the information we have is incorrect or out of date, please contact us to provide updates and we will promptly address the problem.