High Blood Pressure Clinical Trial
Please fill out the pre-screen form to be considered for this clinical trial. Please allow 24-48 hours for one of our staff members to contact you regarding your submission.
Full Name
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Email
*
example@example.com
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
*
Male
Female
What is your preferred method of contact? (check all that apply)
*
Phone Call
Text Message
Have you been diagnosed with high blood pressure (hypertension) by a healthcare provider?
*
Yes
No
Are you currently taking four (4) or more medications to treat your high blood pressure?
*
Yes
No
Is your blood pressure still elevated even though you are taking your prescribed medications?
*
Yes
No
Do you know your most recent TOP blood pressure number (systolic)?
*
Less than 130
130–160
Greater than 160
I don't know
How did you hear about us?
*
Submit Pre-Screening
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