Register for Clinical Trial | East Coast Institute for Research

Sign-up for an ECIR Clinical Trial

If you are interested in joining a clinical trial at ECIR, please complete the form below to begin the process.

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Trial Name
The field is entered when if the patient uses the current trial list and then goes to the trial sign-up form.
Condition
Select your current condition(s).
- Diabetes
- Gastrointestinal Disease
- Heart Disease
- Heart Failure
- Kidney Disease
Applicant Information
Name*
First Last
Email
Phone*
Date of Birth
MM slash DD slash YYYY
Coronavirus Information
Date family member tested positive for Coronavirus
MM slash DD slash YYYY
Date family member received results for Coronavirus
MM slash DD slash YYYY
Address
Address*
Street Address Address Line 2 City State ZIP Code
Terms & Conditions
Terms & Conditions*
What personal information do we collect from the people that visit our website? If you request more information about joining a clinical research study, you may be asked to enter your name, email address, mailing address, phone number, your current disease state(s) or other details to help us determine if you would qualify for a clinical research study that we are currently conducting, or may conduct in the future. When do we collect information? We only collect information from you when request more information by filling out a form our website. How do we use your information? We will use the information you have provided to contact you to see if you may be qualified to participate in a clinical research study. We will attempt to reach you based on the contact information you have provided. If you selected your current disease state(s), we will use this information to ascertain if you might qualify for a clinical research study that we are currently conducting or may conduct in the future. You may request that we no longer attempt to reach you at any time. How do we protect visitor information? Our website is regularly scanned by malware detection software. Your personal information is contained behind secured networks and is only accessible by a limited number of persons who have special access rights to such systems, and are required to keep the information confidential. In addition, all sensitive/credit information you supply is encrypted via Secure Socket Layer (SSL) technology. Third-party disclosure We do not sell, trade, or otherwise transfer to outside parties your personally identifiable information. Third-party links We may include third-party links, which by clicking on the link will take you to another website. We have no responsibility or liability for the content and activities of these linked sites. Fair Information Practices Should a data breach occur: We will notify the users via mail, phone, text, or snail mail within 7 business days of the discovery of a breach If have questions and would like additional information, you may contact: Privacy Officer East Coast Institute for Research, LLC 3550 University Blvd. South, Suite 101 904-854-1354
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Sign-up for an ECIR Clinical Trial

Applicant Information

Coronavirus Information

Address

Terms & Conditions