Assessment - Charter Research

Refer a friend or family member to join research study today and you will receive a $55 Visa gift card when they enroll.

Fill Out The Form

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Refer a friend or family member to join a research study today and you will receive a $55 Visa gift card when they enroll.

Pick a friend or a family member who is new to Charter Research, then fill out the form below.

About You

First Name*

Last Name*

Your Email Address*

Your Phone Number*

About the Person You're Referring

Their First Name*

Their Last Name*

Their Phone Number*

Which Charter Research location is closer to your friend?

Choose a location*

Comments (not required)

Comments

_______________________________________________

Refer another friend?

Refer friend #2

Yes

Their First Name*

Their Last Name*

Their Phone Number*

Which Charter Research location is closer to your friend?

Choose a location*

Comments (not required)

Comments

_______________________________________________

Refer another friend?

Refer friend #3

Yes

Their First Name*

Their Last Name*

Their Phone Number*

Which Charter Research location is closer to your friend?

Choose a location*

Comments (not required)

Comments

_______________________________________________

Refer another friend?

Refer friend #4

Yes

Their First Name*

Their Last Name*

Their Phone Number*

Which Charter Research location is closer to your friend?

Choose a location*

Comments (not required)

Comments

_______________________________________________

Refer another friend?

Refer friend #5

Yes

Their First Name*

Their Last Name*

Their Phone Number*

Which Charter Research location is closer to your friend?

Choose a location*

Comments (not required)

Comments

Fax

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Help us find the cure

Schedule Your Assessment

Sign up for your initial assessment (called a “prescreen”), and we'll give you a call.

One of our professional medical staff will answer your questions and give you more information prior to your in-office visit.

Get More Information

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Your contact information

First Name(Required)

Last Name(Required)

Email(Required)

Phone(Required)

Comments

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Location(Required)

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Street Address

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