Fill out the form below to see if you qualify.
First Name*
Last Name*
Email*
Phone Number*
Have you or someone you know been diagnosed with Alzheimer's disease?
Are you currently taking any medications for Dementia, Memory Loss or Alzheimer's disease? yesnoI have in the past
Are there any other medications that you take?
Do you have any other medical conditions?
Are you the caregiver or the patient? CaregiverPatientUnsure
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