Information Request · No Medical Records
Research Information / Referral Request
This form is designed only to request a follow-up about research or referral pathways. It intentionally collects minimal contact information and should not be used to transmit medical records, diagnosis details, medication lists, Social Security numbers, insurance information, or other sensitive health information.
Not a secure clinical referral form: For actual study screening or time-sensitive referral, call Intercoastal Clinical Research directly at 941-404-4390. If you are a clinician, use your organization’s secure referral/medical-record workflow for protected health information.