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Demographics
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* Indicates required question
Email
*
Your email
Telephone Number
*
Your answer
Full Legal Name (First, Middle, Last)
*
Your answer
Legal Parents/Guardian Full Name if <18
Your answer
This is to confirm that I am the legal [mother/father/legal guardian] of the subject and can provide documentation in the event of confirmation needed.
*
Mother/Father
Legal Guardian
Other:
Required
Date of birth
*
MM
/
DD
/
YYYY
Age
Your answer
Level of Education
*
College or University
Professional Certification
Attending College
Other:
Gender assigned at birth
*
Male
Female
Gender Identity
Your answer
Height in Inches
Your answer
Weight in pounds
Your answer
Race
African American
American Indian
Asian
White
Pacific Islander
Other:
Clear selection
Are you Hispanic or Latino?
Yes
No
Clear selection
Full Address (#, Street, Apt, City, State, Zipcode)
*
Your answer
Emergency Contact Name/Phone Number/Relationship to patient
*
Your answer
How did you hear about us?
Your answer
What name would you like your check written out to IF ever needed to be issued?
Some studies are CLINCARD ONLY!
Your answer
Due to receiving more than $600, for tax purposes please enter your Social Security number.
If you do not feel comfortable imputing your social. Please inform us and we can collect this information in person.
Your answer
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