Enroll in a Trial

To determine if you are eligible for a particular clinical trial, we first must obtain your permission and ask you some basic questions.  These questions may include:

  • Contact information
  • Age
  • Weight
  • Basic medical history
  • List of medications you are taking

These questions will enable us to determine your research eligibility. Pain Research of Charleston DOES NOT share any of the information you disclose to us with any outside entity. All medical information is handled as confidential and we will protect your privacy rights.

* - Required fields

First Name*

MI

Last Name*

Your Email

Street Address

City

State

Zip

Home Phone*

Cell Phone*

Work Phone

Best telephone contact number

What is the best time to call?

Date of Birth

Gender

Primary Care Physician

Physician Phone Number

How did you hear about us?

Trials I'm Interested in
Ex. Fibromalgia, Insomnia, Smoking Cessation, Pain medication, etc.

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