Excel Clinical Research

Site Registration Consent Form


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 Results Comments
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Other:  

 

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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Excel Clinical Research https://excelresearchclinic.com
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Document name: Site Registration Consent Form
lock iconUnique Document ID: e993e881df01e9ce4c3c8ad24e2c15f20aedd310
Timestamp Audit
July 31, 2019 9:35 am PDTSite Registration Consent Form Uploaded by Excel Excel Research - info@excelresearchclinic.com IP 76.214.69.88