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  • New Research Participant Form

    Please allow 15-25 minutes to complete and submit the required information. As a reminder, the information you provide us is CONFIDENTIAL.

  • Patient Information

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  • Emergency Contacts

    Please list an individual who may be contacted in any event when we are unable to reach you after at least 3 attempts.

  • Parent / Legal Guardian Information

    For Patients under Age 18

  • List ALL indivduals who have parental rights and/or have legal guardianship of the minor.

  • Review of Past & Current Health

    Please check any item(s) below that you are currently experiencing and any item you may have experienced in the past. Please indicate when this started for you. Check "N/A" ("Not Applicable") for any condition that does not apply to you, past or present.
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  • Surgeries / Procedures

    Please tell us about any surgeries you have had.
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  • Drug Allergies / Other Allergies

    Please list any allergies you have and the reaction.
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  • Any Other Medical Conditions?

    Please list any other past or present medical conditions, if applicable.
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  • SEXUAL ACTIVITY & CONTRACEPTION

    Regardless of current sexual activity, any patient considering participation in a clinical trial must agree to avoid pregnancy/impregnation of partner and use highly effective forms of contraception for the duration of the trial and 90 days following the trial.

  • Even if you answered “NO” to the above question, please indicate your current or planned method of contraception if you were to become sexually active:


  • Females only

    Please record the date your last menstrual period started. If postmenopausal, please record approximate month and year of last menstrual period. Child / Adolescent patients who have not had first menses, please write "N/A"

  • Substance Use History

    Please provide honest, accurate answers. Your information is confidential.
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  • Family History

    In the section below, please identify if there is a family history of any of the following. If yes, please indicate the family member’s relationship to you in the space provided (father, grandmother, uncle, etc.)
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  • Litigation

  • Clinical Trials Participation

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  • CURRENT MEDICATIONS

  • Please list ALL medications you take, including prescription & over-the-counter medications, recent vaccinations (within the past 5 years), and vitamin supplements. Please make sure t o include medications you take only as-needed (for example, taking Advil f or occasional headache). *If you are taking medications and can’t remember the name, include these too and tell us what you do know and call us ASAP with the details.

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  • Pharmacy

    Where do you go to fill your prescriptions?

  • Upload Photo ID & Other Documents

    Please use the buttons below to upload state issued Photo ID. (For patient under 18, please upload photo of Parent / Legal Guardian Photo ID.)
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  • ACCURACY OF HEALTH INFORMATION & AUTHORIZATION FOR PHYSICIAN CONSULTATION

  • I, * , hereby certify that the health information I provide to the staff of Medical Research Group of Central Florida and any party affiliated with Medical Research Group of Central Florida is true, complete and accurate.

    I understand that the staff physicians will consider the information I have provided to make medical decisions and I understand that giving false, misleading or incomplete information could cause serious adverse health events.

    With my signature below, I hereby authorize the providers of this facility to conduct a consultation for the purposes of determining appropriateness for participation in a current or future clinical trial. I understand that, by signing this form, I am in no way obligated to start or continue participation in any current or future clinical trial nor am I promised eligibility to participate. I also understand that staff providers may recommend treatment according to my medical status and/or mental health and I will take these recommendations into consideration and follow-up with my current mental health provider, primary care physician and/or recommended community resources. Consultation assessments are at the discretion of the provider and may include but are not limited to:

    • Requests for medical records from past and/or current treating providers
    • Collection of demographics and medical history, including medical records
    • Obtaining measurements and vital signs
    • Pregnancy testing
    • Lab testing including urine drug screen
    • Referral for evaluation by another physician/specialist

  • Patient/LAR/Parent Signature:

  • Clear
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