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Site Registration / Consent Form

PERSONAL INFORMATION

Name Date of Birth

Address Apt Age MaleFemale

City State Zip

Phone: Home Work

Other Specify

Ethnic Origin: CaucasianAfrican AmericanHispanicAsianNative AmericanOther

Email:

EMERGENCY INFORMATION

CONTACT PERSON 1

Name

Phone

Address

City State Zip

CONTACT PERSON 2

Name

Phone

Address

City State Zip

Complementary Services

Treatment	Date	Results
Transvaginal Ultrasound (TVU)
CT Scan
Bilateral Hip X-Ray
Bilateral Hip X-Ray
Magnetic Resonance Elastography (MRE)
Fibroscan
Mammogram
Blood Glucose Test
Lipid Panel
Pap Smear
Urinalysis
Electrocardiogram
Other:

Acne

Allergies

Ankle Sprain

Anxiety

Asthma

Atrial Fibrillation

Attention Deficit Disorder

Back Pain

Bipolar Disorder

Breast Pain

Cancer

Childhood Vaccinations

Chronic Bronchitis

Chronic Kidney Disease

Chronic Obstructive Pulmonary Disease

Cold Sores

Constipation

Contraception

Contact Lenses/Solution

Depression

Dermatitis

Diabetes Type 1

Diabetes Type 2

Diabetic Neuropathy Pain

Diarrhea

Dry Eye

Endometriosis

Erectile Dysfunction

Fibromyalgia

Flu/Seasonal Allergies

Heartburn

Hepatitis A/B/C

High Blood Pressure

High Cholesterol

High Triglycerides

HIV or AIDS

Hot Flashes

HPV Vaccine

Irritable Bowel Syndrome

Low Testosterone

Migraines/Headaches

Obesity

Osteoarthritis (OA)

Osteoporosis

Overactive Bladder

Pain Management

Psoriasis

Restless Leg Syndrome

Rheumatoid Arthritis

Shingles

Sleep Apnea

Sleep Disorders/Insomnia

Smoking Cessation

Tendonitis

Tinnitus (Ringing Ears)

Urinary Tract Infections

Yeast Infections

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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Timestamp

Audit

July 31, 2019 9:35 am PDT

Site Registration / Consent Form Uploaded by Excel Excel Research - [email protected] IP 76.214.69.88

May 25, 2023 9:23 am PDT