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Potential Participant Form


We will notify the Study Coordinator, on your behalf, that you would like more information to see if you might be eligible to participate in one of our research studies.

Please fill out the form below and click "Submit" to send a notification request. 

First name:
Last name:
Preferred contact method:
Best time to contact:
Where do you live? (ex: city/state)
How did you hear about us?
Why are you interested in HIRREM?


Quick Reference

Phone: 336-716-9447

Interested in participating? Please fill out the form below.  
Ways to Give
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Disclaimer: The information on this website is for general informational purposes only and SHOULD NOT be relied upon as a substitute for sound professional medical advice, evaluation or care from your physician or other qualified health care provider.

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