Eligibility Questionnaire

See if you or someone you know may be eligible to participate in this clinical research study for the treatment of agitation in participants with Alzheimer’s disease.

If you are interested in learning more about this clinical research study opportunity for yourself or a loved one, please complete the following questionnaire.

Agitation_Dementia_Alzheimer’s_Suven_Icon1

A clinical trial representative will contact you to discuss additional eligibility requirements and answer any questions you may have.

If you or a loved one take part in this clinical research study, the participant must have a caregiver to assist them throughout the duration of the trial.

Please include the information for the caregiver who will be assisting the potential participant throughout the clinical research study.

"*" indicates required fields

Caregiver’s First Name:*

Caregiver’s Last Name:*

Caregiver’s Email:

Caregiver’s Phone Number:*

Caregiver’s Zip Code:*

Preferred contact time:

Potential Participant’s First Name:*

Potential Participant’s Last Name:*

Potential Participant’s Zip Code:*

Potential Participant’s Date of Birth:*

Month

Day

Year

Has the potential participant been diagnosed with dementia of the Alzheimer’s type?*

Yes

Has the potential participant been diagnosed with agitation associated with Alzheimer’s disease?*

Yes

Is the potential participant taking medication for their dementia?*

Yes

Have they been on the same medication and dose for the past 3 months?*

Yes

Future Studies Consent

I agree to be contacted about future studies.

I agree to the Privacy Policy and agree to be contacted about this study via phone, text, or email.

Comments

This field is for validation purposes and should be left unchanged.

This clinical research study is being conducted by Suven Life Sciences Ltd.

6th Floor, Serene Chambers, Road – 5, Avenue – 7
Banjara Hills, Hyderabad, 500034, India

Content on this webpage is intended for the following approved/intended country residents only:
United States

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