GrayMatters Memory Screening and Alzheimer’s Symposium
Registration Form

Tell us how to get in contact with you:
NAME:
ADDRESS:
CITY:
STATE:
ZIP:
DAY PHONE:
EMAIL:
I would like to attend:
The FREE Dementia Screening on August 21th at between 8:30 am – 1:30 and 3:30 - 4:30 pm (testing done in 30 minutes intervals, select time below)
First Time Choice
Second Time Choice
Alzheimer’s Symposium on August 21th from 1:30 – 3:30 pm.
NOTE: The following forms must be completed and brought with you before the screening can take place. Please print and complete or call us at 1-800-381-4551 to request that they be faxed or mailed to you.
Consent for Screening and Information Release Form (.pdf) Dementia Screening Patient Demographics Form (.pdf)