Reasearch New Leads Form

1

What is Your Full Name* This field is required.

First Name

Last Name

2

What is your Best Email?* This field is required.

example@example.com

3

What is your Phone Number* This field is required.

Please enter a valid phone number.

4

Age (Must be 18+)* This field is required.

18 and older

Under 18

5

Do you have a confirmed diagnosis for any of the following?* This field is required.

HIV (Never been on treatment)

HIV (Off of treatment for at least twelve weeks)

Hepatitis C (Not on treatment)

None of the above, but interested in clinical research

6

Do you currently have active Hepatitis C for at least 6 months (not cleared)?* This field is required.

Yes

No

Unsure

7

Are you able to bring medical records and lab results from the last 6 months to your screening visit?* This field is required.We require recent medical records (within 6 months) to confirm eligibility.

YESNO

8

Please share any medical conditions you’ve been diagnosed with.* This field is required.(This helps us match you with future clinical trials.)

9

Are you able to bring in medical records and lab results from the last 6 months?* This field is required.To be eligible, you’ll need to bring a copy of your medical records and lab results to your first visit.

YESNO

10

Can you commit to answering our call in the next 48 hours?* This field is required.Reply YES or NO, and share the best time(s) to reach you (Mon–Fri, 8 AM–5 PM). Feel free to mention anything we should know, like your schedule or availability.