Submit a request – Cognito Clinical Studies

How can we help you?

Your email address

Name

Please enter your first and last name

Primary Contact Number

Please enter your primary phone number

City

Please enter your city

Zip Code

Please enter your zip code

Has someone you care for been diagnosed with Alzheimer's?

Is the person with Alzheimer's over 50 years old?(optional)

Is the person legally blind or deaf?(optional)

Does the person have a history of migraines or seizures?(optional)

Does this person have cognitive or memory problems due to brain trauma or a neurodegenerative disease OTHER THAN Alzheimer’s?(optional)

Topic

What is the nature of your request?

Description

Attachments(optional)

Add file or drop files here