Medical Research South - Clinical Research Trials, Clinical Trial Management and Clinical Research in Charleston, SC

Patients

Enroll in a Trial

To see if you qualify for a clinical trial simply fill out the web form below and press send. If you prefer to fax, visit our printable patient information form. Thank you for your interest. A clinical research coordinator from Medical Research South will follow up once we have received your information.

First Name:                             MI:      Last Name:

Email Address:

Street Address:

City:                                          State:    Zip:

Home Phone:              Cell Phone:                   Work Phone:

What number is the best
to contact you at?

What is the best time to call?

Date of Birth:

Gender:          Race:

Primary Care Physician:                          Phone Number:

Trials I'm Interested in:
Ex. High Blood Pressure, Diabetes, High Cholesterol