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: 


Complementary Services






Current medications:


Current medical conditions:




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.

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Signature Certificate
Document name: COVID 19 & Influenza Site Registration Consent Form
lock iconUnique Document ID: 250d2d2bc41620dbdedd73001e4de173a3dd81d0
Timestamp Audit
October 9, 2020 12:30 pm PSTCOVID 19 & Influenza Site Registration Consent Form Uploaded by Excel Excel Research - info@excelresearchclinic.com IP,,,,