Excel Clinical Research

COVID 19 & Influenza Site Registration Consent Form


COVID-19 & Influenza Site Registration/Consent Form

Name Date of Birth

Address  Apt  Age

City   State Zip  

Phone: Home   Work  

Other   Specify  

Ethnic Origin:   
Email:

Complementary Services

Treatment

Date

Comments

 
 

 

Current medications:


 

Current medical conditions:


 

Comments:


 

Patient Consent

I understand that I will be receiving marketing text messages, emails, and phone calls from Excel Clinical Research staff. I understand that I am providing consent for optional complementary services that may be offered by Excel Clinical Research (in its sole and absolute discretion) or that I have requested and as agreed to by Excel Clinical Research. I also understand that the medical conditions, medications, and demographics that I have provided will be added to the Excel Clinical Research patient database. By signing below, I agree that I have reviewed and agree to the Excel Clinical Research privacy policy attached to this consent form and that I acknowledge the opt-out provisions set forth in the privacy policy.

Leave this empty:

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Signature Certificate
Document name: COVID 19 & Influenza Site Registration Consent Form
lock iconUnique Document ID: 364defe5861bda34c2cc5c372eb672e036dd0cc1
Timestamp Audit
October 9, 2020 12:30 pm PDTCOVID 19 & Influenza Site Registration Consent Form Uploaded by Excel Excel Research - info@excelresearchclinic.com IP 76.214.69.88