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 *
Your answer
Location (City, State) *
Your answer
Phone Number *
Your answer
Brief intro about you. Please provide background on your disease, diagnosis or symptoms. *
Your answer
What medical data do you currently have? *
Your answer
What medical data do you think would be useful to generate for your condition? *
Your answer
What specific research ideas do you want to pursue? -or- What do you hope to gain by collaborating with Research to the People? *
Your answer
[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:
Your answer
A copy of your responses will be emailed to the address you provided.
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