COVID-19 Site Registration Consent Form

COVID-19 Site Registration/Consent Form

Name Date of Birth

Address Apt Age MaleFemale

City State Zip

Phone: Home Work

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Ethnic Origin: CaucasianAfrican AmericanHispanicAsianNative AmericanOther

Email:

Complementary Services

Treatment	Date	Comments
COVID - Nasal Swab
Influenza Nasal Swab

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.

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Your legal name

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I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

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Timestamp

Audit

October 9, 2020 11:09 am PDT

COVID-19 Site Registration Consent Form Uploaded by Sasson Sarooei Sarooei - [email protected] IP 76.214.69.88, 127.0.0.1, 184.168.224.30, 0.0.0.0, 76.214.69.88