Hope Clinical Research

Site Registration Consent Form


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 Results  
 
    
 
    
   
 
    
 
    
 
    
 
    
 
    
 
    
 
    
 
    
 Other:    

 

 

 

 

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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Signature Certificate
Document name: Site Registration Consent Form
lock iconUnique Document ID: e561c486c3e31554d23a7b273a32fc7254edd55c
Timestamp Audit
July 25, 2019 9:38 am PDTSite Registration Consent Form Uploaded by Sasson Sarooei Sarooei - [email protected] IP 76.214.69.88
May 25, 2023 10:13 am PDTHope Recruitment - [email protected] added by Sasson Sarooei Sarooei - [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://hopeclinical.com/
Audit Trail Serial# 7274b31f56e6649c81765497654fe38c