COVID 19 & Influenza Site Registration Consent Form

COVID-19 & Influenza Site Registration/Consent Form

Name Date of Birth

Address Apt Age MaleFemale

City State Zip

Phone: Home Work

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Ethnic Origin: CaucasianAfrican AmericanHispanicAsianNative AmericanOther

Email:

Complementary Services

Treatment	Date	Comments
COVID - Nasal Swab and Influenza Test

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.

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