Pre-Registration
If you're interested in becoming a patient in one of VIN's clinical research trials, please complete the pre-registration form below. A member of VIN will reach out to you with further information to determine your qualifications for treatment. Qualifications for treatment are based on a number of factors including availability, health severity, age, and gender.
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Full name *
Phone number *
Email address *
Date of birth *
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Your home address *
Your medical condition: *
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Please provide a brief synopsis of your medical condition: *
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