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Craig H. Couch, MD
Francisco P. Gomez, MD
Adam D. Horvit, MD
Elizabeth L. Peckham, DO
Terry S. Peery, DO
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Multiple Sclerosis Clinic
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Clinical Trial Enrollment Form
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Insurance Information
Location
Pay My Bill Online
Additional Resources
Our Privacy Policy
Contact
Pay My Bill Online
Patient Portal
Home
About Us
Our Mission
Administrative Team
Clinical Team
Physical Therapy Team
News and Announcements
What's a Neurologist?
Our Providers
Craig H. Couch, MD
Francisco P. Gomez, MD
Adam D. Horvit, MD
Elizabeth L. Peckham, DO
Terry S. Peery, DO
Services
Headache Center
Center for Sleep Medicine
Multiple Sclerosis Clinic
Epilepsy Center
Neuromuscular Center
Movement Disorder Center
Electrodiagnostic Center (EMG and EEG)
Infusion Center
Physical Therapy
>
Physical Therapy Forms
Patient Resources
New Patient Scheduling
Patient Forms
>
Dr. Couch Patient Forms
Dr. Gomez Patient Forms
Dr. Horvit Patient Forms
Dr. Peckham Patient Forms
Dr. Peery Patient Forms
Research
>
Clinical Trial Enrollment Form
Billing Information
Insurance Information
Location
Pay My Bill Online
Additional Resources
Our Privacy Policy
Contact
Pay My Bill Online
Patient Portal
Clinical Trial | Patient Enrollment Form
Fill out the form below to enroll in trials:
*
Indicates required field
Who is completing this form?
*
Myself
Family Member
Other
Patient Name
*
First
Last
Patient Age
*
Patient Phone Number
*
Patient Email
*
Patient Condition
*
Alzheimer's Disease
Cervical Dystonia
Essential Tremor
Huntington Disease
Memory Loss
Mild Cognitive Impairment
Multiple Sclerosis
Parkinson's Disease
Supranuclear Palsy
Which clinical trial are you interested in?
*
ANVS -22002 (Alzheimer's Disease)
324-ETD-202 (Essential Tremor)
283PD201 (Parkinson's Disease)
BK-JM-201 (Parkinson's Disease)
CRL_18_06 (Parkinson's Disease)
CVL-751-PD-003 (Parkinson's Disease)
IkT-148009-201 (Parkinson's Disease)
JZP385-202 (Parkinson's Disease)
PD0060 (Parkinson's Disease)
A35-009 (Progressive Supranuclear Palsy)
How did you hear about us?
*
Referral
Website
Social Media
Flyer
Advertisement
Other
Questions or Comments?
*
When you submit this enrollment form, you must provide accurate and complete information. Upon submission of this form, you consent to your information (name, phone, email, etc.) being transferred and processed by Central Texas Neurology Consultants. If we need to contact you regarding your submission, we may contact you via telephone number or email.
Submit
Please contact Koni Lopez for research of Parkinson's or movement disorders
[email protected]
