ACRIA : Clinical Research: Priority Notification

Patient Priority Notification Program

ACRIA provides notice to persons with HIV infection who might be candidates for current and/or future clinical trials. You will also be notified about our new behavioral studies that focus on aging and HIV. Sign up and receive a FREE subscription to ACRIA UPDATE, our quarterly treatment educational periodical.

Fill out the form and submit it to us online by pressing the SEND button below. Or, if you prefer, print the form out and mail it to ACRIA Priority Notification Program, 230 West 38th St., 17th Floor, New York, NY 10018 or FAX it to: 212-924-3936. If you have any questions regarding the form or would like to talk to someone about clinical trials please call 212-924-3934.

All information will be kept strictly confidential.

Name:
Address:
City, State, Zip:
Home Phone:
OK to send mail: YES NO OK to contact by: Phone? YES NO OK to leave message? YES NO OK to contact by email? YES NO email address:
Business/Other Contact Phone: OK to leave message? YES NO
Gender: Male Female		Date of Birth:
Have you ever taken anti-HIV medications? YES NO Don't know
Race/Ethnicity: African-American Native-American Asian/Pacific Islander Latino/a White Other
Have you ever provided this type of information to ACRIA before? Yes No Don't remember