Apply as a Patient
Research to the People

Note: This form is not HIPAA compliant. If you are concerned about the privacy of your healthcare information, please do not submit this form.

We are currently seeking patient collaborators for 2021!
Email address *
Full Name *
Location (City, State) *
Phone Number *
Brief intro about you. Please provide background on your disease, diagnosis or symptoms. *
What medical data do you currently have? *
What medical data do you think would be useful to generate for your condition? *
What specific research ideas do you want to pursue? -or- What do you hope to gain by collaborating with Research to the People? *
[PRIVATE OPTION] We are exploring working with patients privately. Are you interested hiring a team of researchers from our network to work on your case? *
*We understand that many patients do not desire to publicly disclose their medical status. Working with us privately means your medical records, data and identify will stay private. For private cases there will be fees associated with data generation and analysis.
I understand that if I am accepted to work with Research to the People, my photo, identity and diagnosis will be highly visible to the public. *
Please note: While patient identity is visible online, patient data is only made available to enrolled researchers. Patients are allowed to withdraw their participation and data at any time during the course of working with us.
Additional Notes:
A copy of your responses will be emailed to the address you provided.
Never submit passwords through Google Forms.
This form was created inside of SVAI. Report Abuse