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Social Connections and Dementia
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Overview
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Social Connections
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Step
1
of
3
0%
Enrol below
You are eligible to enrol in this study if you are 65 years of age or over and are exhibiting signs and symptoms of mild or early-stage dementia. Alternatively, you are a carer of someone who matches these criteria.
Select the following the best describes you
(Required)
I am over 65 years of age
I am someone with mild or early-stage dementia
I am a
carer
of someone with mild or early-stage dementia
General Information
Your information is kept private. We do not share any of your information with other parties.
Name (carer)
(Required)
Title *
Dr.
Miss
Mr.
Mrs.
Ms.
Prof.
Rev.
Prefix
First
Last
Name (participant)
(Required)
Title *
Dr.
Miss
Mr.
Mrs.
Ms.
Prof.
Rev.
Prefix
First
Last
Gender of participant
(Required)
Male
Female
Prefer not to say
How should we contact you?
Email of carer
(Required)
Enter Email
Confirm Email
Email
(Required)
Enter Email
Confirm Email
Mobile of carer
Mobile
Are you interested in being contacted about future projects?
Yes, I am interested
To submit your form, answer the question below
(Required)
Email
This field is for validation purposes and should be left unchanged.
