Register your interest

Please feel free to contact us below if you would like to register interest or to discuss any questions you may have.

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 to better respond to your enquiry.

You can also contact us by phone on 020 3311 5228/ 020 3313 5515

Submit your details

Name Are you filling out this questionnaire on behalf of someone else? I am filling this out for myself I am filling this out on behalf of someone else Phone number Email address Preferred method of contact Phone Email Either What is the best time to contact you? Weekday Morning - 9am-Midday Weekday Afternoon - Midday-5pm Any time Specific day or time

If you have selected specific day or time, please add below:

*These questions relate to the person interested in the trial

Age Gender Male Female Other Prefer not to say What type of study are you interested in? A trial with a new investigational drug that targets Alzheimer´s disease A trial with a new drug that tries to relieve the symptoms of Alzheimer´s disease A trial for Alzheimer´s disease that does not involve taking a new investigational drug A trial for the prevention of Alzheimer´s disease [You need to have no memory symptoms for these trial] Please indicate which statement applies to you: I have been diagnosed with Alzheimer´s Disease or Mild Cognitive Impairment I have been diagnosed with Mixed Dementia including Alzheimer´s disease I have dementia caused by another diagnosis for example Vascular Dementia I am experiencing memory issues but do not have a diagnosis I do not have memory issues but I am interested in long term prevention studies Are you willing to travel to Central London to take part? Yes No Some of our trials require a Study Partner, is there someone close to you that is willing to come with you on visits and potentially answer questionnaires? Yes No Unsure Please add any other details you feel are relevant.

If you want to be removed from our contact list, please email If you want to be removed from our contact list, please email <a href="mailto:imperial.memory.research@nhs.net">imperial.memory.research@nhs.net</a>