Epic Clinical Research

COVID 19 & Influenza Site Registration Consent Form


Name Date of Birth

Address  Apt  Age

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Phone: Home   Work  

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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: 3c491301b2d67fda919685d83319c5b94bb898b5
Timestamp Audit
December 2, 2021 11:09 am PDTCOVID 19 & Influenza Site Registration Consent Form Uploaded by Epic Clinical Research - [email protected] IP 76.214.69.88
May 25, 2023 9:55 am PDTEpic Recruitment - [email protected] added by Epic Clinical Research - [email protected] as a CC'd Recipient Ip: 76.214.69.88
Audit trial Qr code
This audit trail report provides a detailed record of the online activity and events recorded for this document.
https://epicclinicalresearch.com/
Audit Trail Serial# 1593a6f8df66f79d4f7e3e02f809d25e