Patient Registration Page | Valiance Research

top of page

Patient Registration

If you are interested in participating in a clinical trial you can register by completing the form below, please note the name of the trial in the comment section if applicable. Once we receive your details we will contact you. You may also email us direct at info@valianceclinicalresearch.com Please note all information is held in confidence in accordance with our Privacy Policy.

First Name

Last Name

Date of Birth

Gender

Phone Number

Address

Country/City

Postal code

I am interested and may qualify for one or more of the following studies/indications

Healthy Volunteer Study

Gout Flare

Obesity/Weight Loss

Uncontrolled Hypertension (High Blood Pressure)

Diabetic Foot Ulcer

Alzheimer's Disease

Asthma

Chronic Obstructive Pulmonary Disease (COPD)

Kidney Disease with High Protein in the urine

Kidney Disease with High Blood Pressure and Protein in the Urine

Ulcerative Colitis

Obesity with History of Cardiovascular Disease

Primary Membranous Nephropathy

Primary Focal Segmental Glomerulosclerosis

Rheumatoid Arthritis

Generalized Pain

Heart Disease

Women's Health

Diabetes

Comment

By checking the box and clicking "send," you agree to allow Valiance Clinical Research to collect and store your protected health information for the use of current and future clinical trials.

Thanks for submitting!

bottom of page