Epic Clinical Research

COVID 19 & Influenza 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

Comments

 
 

 

Current medications:


 

Current medical conditions:


 

Comments:


 

Patient Consent

I understand that I will be receiving marketing text messages, emails, and phone calls from Epic Clinical Research staff. I understand that I am providing consent for optional complementary services that may be offered by Epic Clinical Research (in its sole and absolute discretion) or that I have requested and as agreed to by Epic Clinical Research. I also understand that the medical conditions, medications, and demographics that I have provided will be added to the Epic Clinical Research patient database. By signing below, I agree that I have reviewed and agree to the Epic 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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Signature Certificate
Document name: COVID 19 & Influenza Site Registration Consent Form
lock iconUnique Document ID: d53f75bfaf03643d05ee1eb1f999f57be8ab362c
Timestamp Audit
December 2, 2021 11:09 am PDTCOVID 19 & Influenza Site Registration Consent Form Uploaded by Epic Clinical Research - dtimmons@epicclinicalresearch.com IP 76.214.69.88, 127.0.0.1, 184.168.224.35, 0.0.0.0, 76.214.69.88