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Research Study Information Form

The Mind Body Program of Emory University is recruiting participants for a study on the impact of inflammation on the brain and behavior of patients with depression. Participants who qualify will be compensated for their time. Please complete the following items in order to participate in this study.

Name:
* First:
* Middle:
* Last:
* Phone:
 ) -
 
Is it OK to leave a message by phone regarding the study?
Yes   No
If so, what is the best time to call?
9am-12pm       2pm-5pm      
12pm-2pm       5pm-7pm      
E-mail address:
Is it OK to leave a message by email regarding the study?
Yes   No
How did you hear about us?
Please specify which radio or TV station, name of referring physician, location of poster, etc.:

You may enter a message here: