Register – My Kidney Research

Complete the form below to inquire about participating in one of our clinical trials. You have the opportunity to play an important role in the development of better treatments for future generations.

*Currently only accepting participants with kidney impairments.

"*" indicates required fields

First Name*

Last Name*

Email*

Home Phone*

Mobile Phone*

Phone Opt In

Please text me at the phone number provided above when messages are available. Charges may apply depending on your service plan.

Best Time To Call*

Address*

Street Address Address Line 2 City State ZIP Code

How did you hear about us?*

Do you have a kidney disease?*

Yes

Are you on dialysis?*

Yes

Nephrologist's Name*

Disclaimer: By completing this enrollment form, you consent to provide your personal information to DCR and to allow DCR to retain that information and to use it to notify you in the event you might be a suitable patient for a current or future research study. We will attempt to contact you by phone and/or e-mail if we believe you are a suitable patient for a study. We will retain your information for these purposes indefinitely. You may have your information removed from our database by sending an e-mail asking to be removed to DCRrecruiting@DaVita.com.

Do you agree?*

I agree

I disagree

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