COVID-19 Clinical Trial
Please submit the pre-screen form to be considered for participation in this trial.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
How did you hear about us?
*
Date of Birth
*
-
Month
-
Day
Year
(MUST BE BETWEEN 50-64 YEARS OF AGE TO QUALIFY)
Weight
lbs
Height
ft(in)
In the last 3 months have you tested positive for COVID-19?
*
Yes
No
in the last two weeks have you been in close contact with someone who has tested positive for COVID-19?
*
Yes
No
Do you reside in a chronic care facility, such as a nursing home?
*
Yes
No
in the last 3 months have you received a COVID-19 Vaccine?
*
Yes
No
Do you have any of the following medical conditions: COPD, chronic kidney disease, cystic fibrosis, depression, diabetes, HIV, obesity, pregnant or breast feeding, tuberculosis, dementia, parkinson disease or schizophrenia?
*
Yes
No
Are you a current or former smoker? (tobacco)
Current
Former
Never
Submit
Should be Empty: