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:   

Complementary Services

Treatment Date Results Comments


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.

Leave this empty:

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Signature Certificate
Document name: Site Registration Consent Form
lock iconUnique Document ID: 6c59bd8dd31e4dedc98296b89557b8a0b325d9f8
Timestamp Audit
July 31, 2019 9:35 am PDTSite Registration Consent Form Uploaded by Excel Excel Research - info@excelresearchclinic.com IP,,,