Screening Application

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First Name*
Last Name*
Mailing Address*
City*
State*
Zip*
Work Phone Number*
Cell Phone Number*
Cell receives text messages?*
   
Email Address*
Date of Birth (DDMMMYYYY) *
Gender*
Would You Prefer to be Contacted By:*
   
What Current Medications Do You Take?
Do You Have Any of the Following Conditions? (Choose All That Apply):
     
     
     
     
   
Smoking History*
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I understand that I/my child may have any of the following procedures performed in order to determine qualification for participation in a study involving an investigational medication.

  1. Skin testing, involving a small prick to the surface of the skin, may cause redness, itching and swelling at the site and may possibly continue up to 24-48 hours. Shortness of breath, pulse variations and skin eruptions such as hives are rare.
  2. Blood pressure readings.
  3. Lung function testing.
  4. Electrocardiogram (measurement of electrical impulses of the heart).

There may be the need for additional procedures which are not known at this time.

The above procedures are pre-screening items and do not indicate acceptance into any of our studies. These procedures are free of charge and you will receive no compensation unless accepted into a study.

Your application will be reviewed if you meet any of the requirements for our studies, we will contact you with more information.

I have read and understand the above information.

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