Please fill out this form to request more information about any of the research studies listed on our site. This form submittal is for study inquiry only. Filling out this form does not automatically enroll you in a study. A member of our UACR clinical team will contact you for a phone screening to determine your eligibility to participate in a study.
First Name (required)
Last Name (required)
Date of Birth (mm/dd/yy)(required)
Gender MF
Language(s) Spoken English OnlySpanish OnlyEnglish and Spanish
Your Email (required)
City of Residency
Zip Code
Cell Phone (including area code)
Print AdvertisingRadio CommercialInternet Search (i.e Google Yahoo)E-mail Recieved by UACRCraigslistFacebookMySpaceFriend / Word-of-MouthOther, Specify Below
IF BY RADIO. Please select a station. 92.3 FM (Clásica 92.3)93.1 FM (Rock 93.1)93.9 FM (MIA)94.9 FM (Mega)95.7 FM (El Zol)96.5 FM (Power 96)97.3 FM (The Coast)98.3 FM (Salsa 98)99.1 FM (99 Jamz)99.9 FM (Kiss Country)100.7 FM (Y-100)101.5 FM (Lite FM)102.7 FM (Majic)103.5 FM (The Beat)105.1 FM (Hot 105)105.9 FM (Big 105.9)106.7 FM (Romance)107.5 FM (Amor)560 AM (Sports)610 AM (NewsTalk)710 AM (Mambi)940 AM (NewsTalk)1140 AM (WQBA)Other / Specify below------not applicable---- IF BY PRINT. Please select publication. Community News - Kendall GazetteDiario Las AmericasEl ClarinJob NewsKeys Reporter - Key Westvalue="Keynoter - Key WestMiami-Dade College - Hurricane NewsMiami Herald - Neighbors SectionMiami Herald - SpanishMiami Herald Classified - EnglishMiami Herald Classified - SpanishMailer Received at HomeThe FlyerOther / Specify below-----not applicable---- IF BY OTHER (Notification Source) Please tell us which study you are interested in participating in: (If not included here, please specify in comment box)AcneAcitinic KeratosisADHD (Adult and Child)AllergyAlopeciaAnxietyArthritisAsthmaAtopic DermatitisBack PainChronic PainCommon ColdContraceptionCrohn’s DiseaseDepressionDiabetes Mellitus (Type I and II)Diabetic NeuropathyDyspepsiaEczemaEndometriosisEpilepsyErosive EsophagitisExercise StudiesFatigueFatty LiverFemale Sexual DysfunctionFibroidsFibromyalgiaGERDGoutHair LossHeadachesHerpes Zoster/ shinglesHormone ReplacementHuman Papillomavirus (HPV) VaccineHydrationHypercholesterolemiaHypertensionIncontinenceInfluenza VaccineIrritable Bowel SyndromeInsomniaLethargyMale Erectile DysfunctionMenopauseMenstrual MigrainesMetabolic SyndromeMigrainesMultiple SclerosisObesityOnchomycosisOsteoarthritisOsteoporosisOveractive BladderParkinson’s DiseasePneumoniaPsoriasisRestless Leg SyndromRheumatoid ArthritisRosaceaSchizophreniaSeborrheic DermatitisSinusitisSmallpoxSmoking CessationTinea CapitisUlcerative ColitisUlcers (peptic, duodenal)Urinary Tract InfectionsUterine BleedingUterine FibroidsVaccineVitiligoVulvovaginitisVulvular AtrophyWeight Loss Comments to UACR: * Would you like your name and contact information to be added to the UACR Marketing & Advertising database to keep you informed of future clinical trials? YESNO List All Medications your are currently taking, including Medication, Dosage, Frequency, Start Date, Stop Date or Continuing, Indication (reason) * (ex. Allegra, 10 mg, 1 a day, June 2007, Continuing, Allergies)