Survey - Cognitive Assessment Interest Survey

1.

Please provide your contact information

*

Name:

First Name Required	Last Name Required

*

Email: Required

*

Street 1: Required

*

Street 2: Required

*

City/Province/Postal:

City Required	Postal Required

Yes, I would like to receive email from Alzheimer Society

Yes, I would like to receive postal mail from Alzheimer Society

*2.

Question - Required - Please provide your date of birth, including year (ex January 10, 1955)

3.

Question - Not Required - Do you have memory concerns?

4.

Question - Not Required - Do you currently have a diagnosis of Dementia or Mild Cognitive Impairment?

Yes

No