Eligibility Screening - Fast Track Clinical Trials

Important Information

This screening questionnaire is for informational purposes only and is not a substitute for consultation with a healthcare professional. All information provided will be kept confidential and secure in accordance with HIPAA guidelines.

Personal Information

First Name*

Please provide your first name.

Last Name*

Please provide your last name.

Email Address*

Please provide a valid email address.

Phone Number*

Please provide a phone number.

Age*

Please provide your age (must be 18 or older).

Gender*

Please select a gender option.

Zip/Postal Code*

Please provide your zip/postal code.

Additional Information

Is there anything else you would like to share about your health or interest in clinical trials?

How did you hear about our clinical trials?

Consent

By submitting this form, you are giving Fast Track Clinical Trials permission to collect and process your personal and health information for the purpose of determining your eligibility for clinical trials.

Your information will be handled in accordance with our privacy policy and HIPAA regulations. We may contact you regarding clinical trials you may be eligible for.

You can withdraw your consent at any time by contacting us.

I consent to the collection and processing of my personal and health information for the purpose of clinical trial eligibility screening.*

You must agree to the consent terms to continue.

I would like to receive information about other clinical trials and health-related news from Fast Track Clinical Trials.

Clinical Trial Eligibility Screening

Important Information

Personal Information

Medical History

Trial Participation

Additional Information

Consent