HGHRT Study Participation - CNS - Center for Neurological Studies

Interested in participating in the CNS HGHRT Study? Download the official flyer and submit your details below:

(Click to enlarge and print the flyer)

Submit Your Details for Participation

For more information reach us at the number below or fill out the form below. We will contact you to see if you qualify for the study.

Center for Neurological Studies
330 Town Center Drive – Suite 710
Dearborn, MI 48126
Email: vijay@neurologicstudies.com
Phone: 313-228-0930 – Ext. 103

HGHRT Study

There are two parts below. Please make sure you fill out the general information form and the Authorization to Release Medical Information form below.

By submitting this form, you are agreeing to allow CNS to reach you to learn if you qualify for this study.

Name*
First Last
Phone*
Email*
Were you signed by the NFL at some point?*
- Yes
- No
Do you experience any of the following? (Check all that apply.)*
- Chronic fatigue, particularly since leaving football
- Sleep abnormality: excessive sleeping or difficulty sleeping
- Depression or anxiety especially since leaving football
- None of these apply to me
Have you been diagnosed with diabetes?*
- Yes
- No

Authorization to Release Medical Information to CNS Form

Please fill out, sign and send or fax us the Authorization to Release Medical Information form below.

Please send the form to:

Center for Neurological Studies
Center for Neurological Studies
330 Town Center Drive – Suite 710
Dearborn, MI 48126
Email: vijay@neurologicstudies.com
Fax: (313) 228-0930
Phone: 313-228-0930 – Ext. 103