ANGIOKERATOMAS PATIENT INSIGHTS STUDY

Thank you for your interest in participating in our paid patient interview project. We invite you to complete this voluntary questionnaire to help us determine if you meet the criteria for the paid interviews.

If you meet the criteria, we will reach out to schedule a 30-minute Zoom call with Simply Patient. After completing the call, you’ll receive $100 as gratitude for your time. 
Submission of this form does not guarantee that you will be selected for a paid interview.

Disclaimer: By completing and submitting this questionnaire, you acknowledge and accept that Simply Patient LLC (“Simply Patient”) are conducting a preliminary screening process to assess potential participants for this project. Simply Patient reserves the right to screen, select, or decline any individual at its sole discretion, and reserves the right to terminate or modify the project and/or recruitment process at any time without notice. Only eligible for United States residents.

Data and Privacy Notice: Simply Patient is committed to protecting your privacy. The information collected through this form will be used solely for the purpose of evaluating potential participants for this project. Your data will be stored securely and treated confidentially in compliance with applicable data protection and privacy laws. By proceeding, you expressly consent to the collection, retention, and use of your personal information, including any health-related data, as outlined in this questionnaire.

If you have any questions, please email us at recruiting@simplypatient.com.

The following questions are optional. We are collecting this information to better understand the diversity of participants in the study and to ensure that we can describe the participant population in an aggregated, de-identified way.

Your responses will be kept confidential and used only for research purposes. You may skip any question you do not wish to answer.

By submitting this form and information, you expressly agree to the following:

Simply Patient LLC and its affiliates may collect, retain, and use the information you provide in this form, including any health-related information, for any purposes related to this project. Simply Patient will not share your information with any external parties beyond those necessary to conduct this screening process and interview selection. You are voluntarily providing your information and assume responsibility for any and all disclosures you make in this form. 

By completing and submitting this form, you further release Simply Patient LLC and its affiliates from any and all claims, demands, liabilities, or damages arising out of or in connection with your participation in this screening process or any subsequent interview, including but not limited to claims related to privacy, data protection, or medical information. Simply Patient shall not be held liable for any incidental or consequential damages, including loss of privacy or exposure of medical data, that may result from participation in this process.

• I understand and agree to the terms and authorize Simply Patient to use my information for the purposes described above.
• I understand that this is a preliminary screening questionnaire for a research study and does not guarantee participation or compensation.
• Participation is voluntary and questions may be skipped.
• The information provided will be used only to determine eligibility and will be kept confidential.
• If eligible, I consent to being contacted for scheduling the interview.