Clinic and Biomarker Testing Survey
Clinic / Organization Name
*
Primary Contact Name
*
First Name
Last Name
Role / Title
*
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Clinic Address
*
Website
Clinic Type
*
Approximate Number of Patients Seen per Month
*
1–50
51–150
151–300
300+
Do you work with quantitative biomarker testing or immune-related assays?
*
Yes
No
If yes, please describe your biomarker testing or immune-related assays work
Primary motivation for offering assay once IRB approval is granted
*
Participate in emerging biomarker research
Support wellness and recovery-tracking programs
Enhance internal research initiatives
Provide patients with advanced data-driven insights (non-diagnostic)
Other (describe)
Estimated number of tests per month anticipated ordering
*
1–10
11–25
26–50
51–100
100+
Ordering timing preferences
*
Immediately
Within 30 days
Within 60–90 days
Undecided
Ability to draw blood onsite
*
Yes
No
Sometimes
If no, current work with
Mobile phlebotomy partners
Local draw stations
In-house collection planned
Not sure yet
Shipping capabilities
*
Yes
No
With training / guidance
Program structure preferences
*
Pay-per-test
Prepaid bulk test credits (discounted)
Monthly subscription block (e.g., 25–50 tests/month)
Not sure — need more information
Interest in co-branding opportunities
*
Yes
No
Participation in multi-site research summaries or white papers
*
Yes
No
Interest in beta testing new biomarkers in the future
*
Yes
No
Data and reporting preferences
*
Optional training for staff on interpreting research-only results
*
Yes
No
Maybe
Readiness and priority status - open response
Do patients request access to research-based immune/protein biomarker testing?
*
Yes
No
Estimated number of interested patients
Willingness to provide non-identifiable aggregate feedback
*
Yes
No
Compliance acknowledgment
*
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