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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.

Volunteer Information Submission - Vertex 1

Disclaimer: By entering and submitting (sending) my information, I have consented to provide personal information to DaVita Clinical Research (DCR), allow DCR to retain that information, and to use that information to notify me in the event I might be a suitable volunteer for a current or future research study . By providing this information, I am allowing DCR to contact me, by phone and/or e-mail, should DCR find that I am a suitable volunteer patient for a clinical research study. DCR will retain my information for these purposes indefinitely. At any time, I may have my information removed from the DCR database, by emailing my removal request to @@@@.

First Name*
Last Name*
Date of Birth
MM slash DD slash YYYY
Email*
Phone*
Mobile Phone
Best Time to Call
Address 1
Address 2
City
State*
Zip Code
How did you hear about us?
Do you have a kidney disease?*
- Yes
- No
Are you on dialysis?
- Yes
- No
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
Phone
This field is for validation purposes and should be left unchanged.