Refer a Patient

If you are interested in being contacted by one of our team members regarding either the VISTA clinical trial pre-screening program or the no-cost genetic testing program, please fill out the brief questionnaire below.You will also have the option to refer a patient to be contacted directly regarding the VISTA pre-screening program.

How did you hear about the VISTA clinical trial? (check all that apply)

    *Please select at least one of the check boxes.

Please provide your contact information so one of our qualified healthcare professionals can contact you regarding the VISTA clinical trial.

Do you want to refer your patient to the vista clinical trial now?

Submit Your Patient’s Contact Information

If you are referring a patient 18 years or older, please provide their contact information in the form below.

If you are referring a patient under the age of 18, please provide the minor’s parent or legal guardian’s contact information.

A nurse from the study team will contact your patient (or their parent / legal guardian) to review eligibility and discuss the VISTA clinical trial.

Please, only provide contact information for your patient or their legal guardian.

Thank you for completing the questionnaire.

- I understand that the personal information I have provided may be collected, shared, used and/or transferred to the VISTA clinical trial study team for the sole purpose of enabling me or the contact person to be contacted regarding a clinical trial.

- If I am referring a patient, the name and phone number I have provided belong to my patient or their parent or legal guardian, are correct, and I attest that the contact person is interested in being contacted regarding a clinical trial (in order to help prevent unauthorized use of this service).

- I confirm that I have read and understood the Legal Notice and Privacy Policy.

- The contact person is 18 years or older.

- If I am referring a patient, my patient has agreed to be contacted via phone by Serva Health.