Please provide your contact information

Thank you for completing the questionnaire.  It appears you or your child may qualify for the VISTA clinical trial.  Please only provide your contact information in the form below and click the submit button  A nurse from the study team will contact you to review eligibility and discuss the VISTA clinical trial.  

Please, do not provide any information about anyone but yourself.

Contact’s First name

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Contact’s Last name

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Contact’s Address 1

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Contact’s Address 2

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Contact’s City

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Contact’s State/Province

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Contact’s Postal Code

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Contact’s Phone Number

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Contact’s Email address

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Contact’s Country

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Potential Participant Healthcare Provider

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Best time of day to contact:

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Privacy is very important to us. If we are unable to reach you, may we leave a message?

Yes

No

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When you submit the contact information by clicking below, it is forwarded directly to the VISTA trial nursing team at Serva Health. Submitting this information is not a commitment to participate in the VISTA clinical trial, but rather simply exploring the possibility of being able to participate if qualified.

By checking the box below, I understand that the personal information I have provided may be collected, shared, used and/or transferred to the VISTA clinical trial study team for the sole purpose of enabling me to be contacted to see if myself or the potential participant is eligible to take part in a clinical trial, and if appropriate, to assist in enrolling into the VISTA clinical trial. I acknowledge that I / my child / loved one may withdraw interest in participating in a trial at any time by speaking with a member of the study team.

By checking this box, I verify that:

  • The name and phone number I have provided belong to me, are correct, and that I am interested in myself / my child / loved one participating in a clinical trial (in order to help prevent unauthorized use of this service).
  • I am 18 years or older.
  • I am the parent, legal guardian, or otherwise legally authorized to act on behalf of the potential participant.
  • I agree to be contacted via phone or email.
This is a required question. Please answer and resubmit.