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Abraham Research Participants

Contact Us

Abraham Research, PLLC.

2300 Chamber Center Drive, Suite 102

Fort Mitchell, Kentucky 41017

Phone: 859-371-3797

Fax: 859-371-3799

Email: info@abrahamresearch.com

 

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CLINICAL TRIALS - SIGN-UP FORM

To determine if you qualify for a research study, we will ask you some questions about your medical history and present condition. This survey will remain confidential and will be reviewed by the research staff only. This information is for pre-screening purposes only and does not guarantee qualification for a study. It may be kept on file for future studies for which you may be eligible. If you do not qualify for a study or choose not to participate, at your request we will destroy the information submitted in this survey.

Do you permit Abraham Research to retain the information you submit on this form on file for future studies for which you may be eligible?

 

Yes   |   No

Patient Information

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*First Name

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Date of Birth

*Sex

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*Home Phone

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Alternate Phone

Email Address

*Street Address

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*City

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Clinical Trial Interest

Allergies
Allergic Rhinitis
Asthma
COPD
Hay Fever
Hives, Chronic
Urticaria, Chronic
Diabetes
Other

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