Northwest Research: Potential Patient Form

If you are interested in participating in a study with Northwest Research, please submit your information using the form below and we will contact you. We are currently enrolling studies for Adult and Adolescent Asthma, Chronic Cough, and COPD.

By submitting your information, you consent to be contacted by a member of our staff now or in the future. If you have any questions, give us a call at (503) 238-6233.

Once your submission is received, we will contact you within 2 business days to discuss study options and to schedule a complimentary consultation to evaluate your symptoms. We do not share or sell your information. We look forward to speaking with you!

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* 1. Your Name

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* 2. Phone Number

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* 3. Email Address

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* 4. Birth Year

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* 5. How would you prefer to be contacted?

By phone call

By email

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* 6. How did you hear about Northwest Research?

Physician Referral

Newspaper

Radio

Television

Friend

Social Media

Other (please specify)

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* 7. Privacy Statement

Per the federal Health Insurance Portability and Accountability Act (HIPAA), all individually identifiable health information that is provided to Northwest Research Center (NWRC) in the course of submission, evaluation, assessment, and treatment is considered “Protected Health Information” (PHI). This information includes demographics and relates to your past, present, and future physical and/or mental health or condition and related health care services. NWRC will maintain all information in a confidential and secure manner, ensuring that only authorized personnel will have access to your PHI. Unless required by state or federal law, NWRC will not release or disclose your PHI without your prior written authorization. You are permitted to review and request copies of the PHI, as well as withdraw the authorization for NWRC’s use of the information, at any time. Your PHI will be used to evaluate your potential for participation in our clinical research studies. If you believe the information we have is incorrect or out of date, please contact us to provide updates and we will promptly address the problem.

By submitting your information, you consent to be contacted by a member of our staff now or in the future.

I have read and acknowledge the Privacy Statement and consent to a member of Northwest Research staff contacting me now or in the future.