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Sponsors | CROs
Health Professional
Meet The Team
Educational Resources
About
Blog Posts
VCR Referral Form
Valiance Clinical Research Referral Portal
Submit a Referral
Referrer Information
Referrer Code
Enter your assigned code using up to 10 letters or numbers.
PATIENT INFORMATION
Patient First Name
Patient Last Name
Patient Email Address
Patient Phone Number
Optional
Patient Date of Birth
Preferrered Language
English
Spanish
Patient Address (INCLUDE CITY AND STATE)
STUDY AND CLINICAL INFORMATION
Study or Medical Condition or Interest and preferred Valiance Clinical Research Site
Acute Gout Flare – Tarzana
ADPKD (Autosomal Dominant Polycystic Kidney Disease) – Huntington Park
Asthma – Tarzana
Atopic Dermatitis – Tarzana
Cardiovascular Prevention – Huntington Park
Cardiovascular Prevention – Northridge
Cardiovascular Prevention – Tarzana
Chronic Obstructive Pulmonary Disease (COPD) – Tarzana
Crohn's Disease – Tarzana
Diabetic Foot Ulcer – Northridge
Diabetic Foot Ulcer – San Diego
Diabetic Kidney Disease – Tarzana
End-Stage Kidney Disease (ESRD) on Dialysis – Northridge
End-Stage Kidney Disease (ESRD) on Dialysis – Tarzana
End-Stage Kidney Disease Hemodialysis (CVC) – Northridge
End-Stage Kidney Disease Hemodialysis (CVC) – Tarzana
Heart Failure + Obesity – Huntington Park
Heart Failure + Obesity – Northridge
Heart Failure + Obesity – San Diego
Heart Failure + Obesity – Tarzana
Hidradenitis Suppurativa (HS) – Tarzana
High Blood Pressure (HTN) – Tarzana
Liver Disease – Tarzana
Primary Focal Segmental Glomerulosclerosis – Huntington Park
Primary Focal Segmental Glomerulosclerosis – Tarzana
Ulcerative Colitis – Tarzana
Reason for Referral or Relevant Diagnosis
Primary Care Provider or Treating Provider
Optional.
SUPPORTING DOCUMENTS
Patient Face Sheet or Demographics
Additional Supporting Documents
Optional. PDF, JPG, or PNG / Maximum 10mb
Optional. PDF, JPG, or PNG / Maximum 10mb per file
CONFIRMATION
Privacy Policy Acknowledgment (Required)
I have read and agree to the
Valiance Clinical Research Privacy Policy
regarding the collection, use, and protection of my personal information.
Authorization to Collect and Use Information (Required)
I confirm that I am authorized to provide or submit this information for referral purposes and authorize Valiance Clinical Research to use it to evaluate potential study eligibility and contact the referred individual, as permitted by applicable laws.
Certification of Information (Required)
I certify that the information I have provided is true, accurate, and complete to the best of my knowledge.
Consent to Be Contacted (Optional BUT Recommended)
I consent to being contacted by Valiance Clinical Research by phone, email, or text message regarding my inquiry, referral, or potential participation in clinical research studies.
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