Thank you for your interest in clinical trials at the Imperial Memory Unit, Charing Cross Hospital.

If you are interested in screening for one of our clinical trials, please fill out the form below and one of our team will be in touch. You are not required to answer all the questions, though any details you are happy to provide will help us better assess your suitability for participating in a clinical trial.

We will keep your data for five years, and it will not be shared with any third parties. If you are not suitable for our currently recruiting trials, we might contact you in the future about new trials, which you may be suitable for depending on your answers to this form. If you do not want us to keep your information, please let us know by contacting us on the details below.

You can contact us by phone on 020 3311 5228, email on

Contact details and general questions

Please provide your contact details below

Study partner

Our trials requires you to have a study partner, this is someone you have weekly contact with and who knows you well. They will need to join you for some visits (average of eight visits over four years) to answer some questionnaires about you and your health.

Medical questions

These questions are to see if there is anything in your medical history that would exclude you from any of our trials.