Thank you for your interest in studies at Miramax Clinical Research.

This form will allow us to collect information about your health history. Your participation in completing this form is completely voluntary.

Your information will only be seen by researchers at Miramax Clinical Research. The information we collect will be kept private and used only for research studies at Miramax Clinical Research. Your health information will not be shared without your permission or except as required by law. Information collected on this form will be stored in our secured recruitment database. If you agree to being included in the recruitment database, you can request at any time that your name and information be removed.

Don’t hesitate to ask us something. Email us directly [email protected] or call us at (954) 363-1163.