1 2 3 4 5 6 7 8 9 10 IndividualAre you interested in our clinical trials in the USA or UK?*USAUKTitle*Please selectDrMrMrsMsSirLordLadyProfessorFirst Name*Surname*How old are you?*Please selectUnder 5050-5555-5960-6465-85Over 85Email* PhoneYour preferred clinic*Please selectLondonGuildfordBirminghamPlymouthWashingtonHow did you hear about us?*Please selectFacebookGoogleTelegraphEvening StandardMetroBirmingham MetroWord of MouthReferralRe:Cognition Health EventPlymouth MagazinePlymouth HeraldWestern Morning NewsRadio Plymouth Have you been diagnosed with Alzheimer's Disease, Mild Cognitive Impairment, or have you experienced memory problems for more than 6 months?*Please selectI have been diagnosed with Alzheimer's DiseaseI have been diagnosed with Mild Cognitive ImpairmentI have experienced memory problems for over 6 monthsI do not have any memory problems Do you have anyone who would be able to accompany you to your appointments?*Please selectYesNo Are you willing to take a trial medication if you are found to be eligible?*Please selectYesNo Have you been diagnosed with cancer in the last 5 years (excluding basal and squamous cell carcinoma)?*Please selectYesNo Do you have any metal work in your body?*Please selectYesNo Do you have a pacemaker?*PleaseYesNo Are you currently taking any anti-coagulants? (e.g. warfarin)*Please selectYesNo Have there been any changes to your medication in the last 30 days?*Please selectYesNo Have you ever experienced a fit, stroke, or seizure?*Please selectYesNo This iframe contains the logic required to handle Ajax powered Gravity Forms.