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

"*" indicates required fields

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

This field is for validation purposes and should be left unchanged.

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

Location(Required)

Your contact information

First Name(Required)

Last Name(Required)

Email(Required)

Phone(Required)

Comments

This field is hidden when viewing the form

Location(Required)

This field is hidden when viewing the form

SMS Opt-In(Required)

This field is for validation purposes and should be left unchanged.