Referral Consent Form
Medical Information Release Form

How to use this Form:
Use one Form per individual. To reduce "Banner", click on its "UPPER" right arrow.
Type in the Form, on screen response, (fill out applicable blanks). 
Press "TAB" to move between blank spaces. When finished, please print the Form.

Name Of Person Providing Consent:
First Name. Middle Initials. Family Name.
Date Of birth: Month.   . Day. Year.
Address:  Number.  Street.  Apt #. 
City.      Zip Code.
Day Phone Number Area Code.    Number.
Evening Phone Number Area Code.    Number.
Mobile Phone Number Area Code.    Number.
E. Mail Address .

Authorization To Release Information:
I hereby authorize Consumer Support to give the above contact information to clinical trial groups so that they can contact me about clinical research trials for investigational medications for:
 
.  Depression .  Alzheimer's Disease .  Anxiety
.  Bipolar Disorder
 (Manic Depression)		 .  Schizophrenia .  Memory Problems
.
I want to receive additional information about clinical research Yes. No.
I want to be contacted by site research staff Yes. No.

_____________________________________________________     _____________________
Signature of Individual or Legal Guardian                                                                         Date

Please Print Completed Form And Mail It To:
Consumer Support
P.O. Box 748, Lake Forest, California 92630-0748, USA

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