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Be the first to learn about upcoming clinical research studies!
Interested in potential upcoming studies? Please complete this form to be added to our contact list and to help assess eligibility. Completion of this form is entirely voluntary and you can choose to discontinue at any time.
First Name
*
Last Name
*
Your Email
*
Phone Number
Date of Birth
DD dash MM dash YYYY
Are you male or female?
Male
Female
Height
Unit
cm
ft+in
Weight
Unit
kg
lb
Ethnicity: Select all the apply
Caucasian
Black
Hispanic
Asian
Indigenous
Do you have diabetes?
Yes, Type I
Yes, Type II
No
Do you regularly smoke cigarettes (including e-cigarettes)?
Yes
No
Do you regularly smoke marijuana?
Yes
No
I provide consent for INQUIS to maintain the personal information provided in this survey and to contact me about participation in future studies.
*
Yes
Comments
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