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Eligibility Questionnaire

Study Eligibility Questionnaire

If you wish to be considered for study participation you may call us at (888) 317-6262, email us or complete the questionnaire below:

Health Background:

In summary, what seems to be your health concern?

For what diagnosis are you seeking treatment?

For how long have you experienced these symptoms?

What Medications are you currently taking?
(Please include all medications you take regularly: prescription, over the counter and herbal)

What is your age?

Male     Female

Are you currently pregnant?
Yes     No

Do you intend to get pregnant in the next 6 months?
Yes     No

When have you last used street drugs?
(eg: Marijuana, Cocaine, Methamphetamines)
Never     More Than A Year Ago     Currently

Would you be able to travel to our clinic in the Upper West Side of Manhattan?
Yes     No

Have you participated in a clinical trial in the last 6 months?
Yes     No

Contact Information:




Best Time To Call:

Optional Message:

Current Clinical Trials

View All Current Clinical Trials

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