Epic Clinical Research

Site Registration/Consent Form


PERSONAL INFORMATION

Name Date of Birth

Address  Apt  Age

City   State Zip  

Phone: Home   Work  

Other   Specify  

Ethnic Origin: 

 
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 Comments
 
 
   
   
   
 
   
 
   
 
   
 
   
 
   
 
   
 
   
 
   
 Other:    

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.

Leave this empty:

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Signature Certificate
Document name: Site Registration/Consent Form
lock iconUnique Document ID: c0bfdc483b9a560282e1e30b23cbc414be7de993
Timestamp Audit
December 2, 2021 9:07 am PDTSite Registration/Consent Form Uploaded by Epic Clinical Research - info@epicclinicalresearch.com IP 76.214.69.88, 127.0.0.1, 184.168.224.34, 0.0.0.0, 76.214.69.88