Clone of Contact Scottish Brain Sciences (Self 2025)

I am completing this form*

For myselfOn behalf of someone else
Your name*

First NameLast Name
Your email*
Your telephone number*
Your date of birth*

DayMonthYear
Your postcode*
How would you like us to contact you?*

EmailTelephone
On whose behalf are you signing up?*

Spouse/partnerParentSiblingFriendPatientOther
Their name*

First NameLast Name
Their date of birth*

DayMonthYear
Their postcode*
Do you have a diagnosis of Alzheimer’s disease, Mild Cognitive Impairment or another form of dementia?*

Yes, I have an Alzheimer’s disease diagnosisYes, I have a Mild Cognitive Impairment diagnosisYes, I have a diagnosis of another form of dementiaNo, I do not have a diagnosis of any of the above
Are you currently concerned about changes to your memory or cognitive thinking?*

Yes, I am concerned about changes to my memory or other thinking problemsNo, I am not currently concerned about my memory or other thinking problems
Do you have any family history of Alzheimer's or any other dementia?*

YesNoDon't know
If yes, which relatives and what condition(s) did they have?
Do they have a diagnosis of Alzheimer’s disease, Mild Cognitive Impairment or another form of dementia?*

Yes, they have an Alzheimer’s disease diagnosisYes, they have a Mild Cognitive Impairment diagnosisYes, they have a diagnosis of another form of dementiaNo, they do not have a diagnosis of any of the above
Are they currently concerned about changes to your memory or cognitive thinking?*

Yes, they are concerned about changes to my memory or other thinking problemsNo, they are not currently concerned about my memory or other thinking problems
Do they have any family history of Alzheimer's or any other dementia?*

YesNoDon't know
If yes, which relatives and what condition(s) did they have?
If you are not currently eligible for our trials, would you like to join our register to be contacted about future trials?*

YesNo
If they are not currently eligible for our trials, would they like to join our register to be contacted about future trials?*

YesNo
Would you like to receive news from Scottish Brain Sciences including updates on the trials and studies we are running?*

YesNo
Please read our Privacy Policy
How did you hear about us?*

Internet searchWord of mouthSocial mediaPress/newsEventHealthcare professionalRadioTVOther
Is there anything else you would like us to know?
Please verify that you are human*
Should be Empty: