Practice Based Clinical Research Referral Network
Thank you for your interest in supporting the School of Dentistry's research mission by enrolling as a participating dental office in the Practice Based Clinical Research Referral Network. By filling out this form you are agreeing to receive a quarterly email with information and flyers for studies that are currently recruiting at the dental school.
It is important to note that any patients you refer for specific trials will be screened to see if they qualify, and, if they do, they will only receive treatment related to the study. We will work with your office to coordinate any other dental care they may need during the study period and we will refer them back to you for all further care on completion of the study.
If you have any questions please reach out to us at
or visit our website at
Again, thank you so much for your support.
Sign in to Google
to save your progress.
Dentist or Practice Name
Address of Practice
Practice Phone Number
Email address where you would like to receive the flyers
Type of Practice
Are there other providers in your office that you would like to receive this information (Dental hygieneists or other dentists)? Please list their name (s) and email here
How did you hear about the referral network?
Never submit passwords through Google Forms.
This form was created inside of University of Michigan.