Patient Interest and Clinic Referral Survey
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Date of Birth
*
-
Month
-
Day
Year
Date
City, State, Country
*
Do you have a healthcare provider?
*
Yes
No
Provider Name
Clinic Name
Clinic City and State
Preference for care
*
Use existing provider
Be referred to clinic
Either is fine
Interest in test
*
General curiosity
Tracking recovery
Participation in research
Referred by clinician
Other
Other
Previous participation in similar tests?
*
Yes
No
Description of previous participation
Wellness concerns
*
Long-term recovery
Inflammation
Fatigue
Exercise recovery
Other
Other
Duration of wellness concerns
*
Less than 1 month
1-3 months
3-12 months
1-3 years
3+ years
Prefer not to answer
Ability to travel for appointments
*
Yes
No
Possibly depending on location
Clinic preference
*
Within 15 miles
Within 30 miles
Statewide
Mobile phlebotomist
Preferred appointment times
*
Morning
Afternoon
Evening
Weekends
Flexible
Notification preference
*
Email
Text message
Phone call
Any method
Would you like to receive research updates?
*
Yes
No
Do you consent to share your information for research purposes?
*
Yes
No
How did you hear about us?
*
Friend or family
Clinic or healthcare provider
Social media
Online search
Conference or event
Other
Other
Additional information
Acknowledgments (please check all that apply)
*
I understand that test availability may vary
This survey is not medical advice
I consent to be contacted for follow-up
Submit
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