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Long Beach Memorial Medical CenterWomen's Health Research Registry™

Join the Women’s Health Research Registry™

230 Women Have Joined

CONSENT TO PARTICIPATE IN A RESEARCH REGISTRY

SIGNATURE BY THE SUBJECT OR THE SUBJECT’S LEGAL REPRESENTATIVE:

Click "I Accept" to consent to being part of the registry.

 

Printable Consent Form and Registry Questionnaire

For participants completing a paper copy of the registry questionnaire, please print the consent form and registry questionnaire. Sign the consent form and submit it with your completed questionnaire.
Download Consent Form and Registry Questionnaire

Submit the Consent Form and Questionnaire to:

MemorialCare Heart & Vascular Institute Center
Center for Women’s Cardiac Health & Research
Women's Health Research Registry™
2865 Atlantic Ave, Suite 210
Long Beach, CA 90806
Phone: (562) 933-2460
Fax: (562) 933-2462

 

MemorialCare Health System is a not-for-profit integrated delivery system that includes six top hospitals – Long Beach Memorial, Miller Children's Hospital Long Beach, Community Hospital Long Beach, Orange Coast Memorial, and Saddleback Memorial Laguna Hills and San Clemente; medical groups – MemorialCare Medical Group and Memorial Prompt Care; an Independent Practice Association (IPA) Greater Newport Physicians; MemorialCare HealthExpress retail clinics; and numerous outpatient health centers throughout the Southland. Our community-based hospitals are located in Southern California in both Los Angeles County and Orange County. Copyright © 1999 - 2014, Memorial Health Services. All rights reserved.