Hope Clinical Research

COVID 19 Site Registration Consent Form


COVID-19 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 Hope Clinical Research staff. I understand that I am providing consent for optional complementary services that may be offered by Hope Clinical Research (in its sole and absolute discretion) or that I have requested and as agreed to by Hope Clinical Research. I also understand that the medical conditions, medications, and demographics that I have provided will be added to the Hope Clinical Research patient database. By signing below, I agree that I have reviewed and agree to the Hope 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: COVID 19 Site Registration Consent Form
lock iconUnique Document ID: 84e300cfd853c1c15cbdd7911bd4db591c4b9154
Timestamp Audit
October 9, 2020 11:09 am PDTCOVID 19 Site Registration Consent Form Uploaded by Sasson Sarooei Sarooei - info@hopeclinical.com IP 76.214.69.88