CAPRIO Eligibility Form

CAPRIO Eligibility Form

This is an eligibility form for the MIT CAPRIO clinical study. Please fill out only if you are interested in becoming a participant for the MIT CAPRIO clinical study. Your participation in this clinical study is completely voluntary. Your completion of this form does not guarantee nor force your participation in the CAPRIO clinical study.
Participant ID
Name

First NameLast Name
Date
What is your birth month?
What is your birth year?
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Do you currently reside in the United States?
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
In order to participate, you will be required to have access to a capillaroscope (capillary microscope), be willing to purchase a capillaroscope, AND/OR have existing capillaroscopy images that you can upload.

You will NOT be reimbursed for the cost of a capillaroscope.
Do you have access to a capillaroscope, are you willing to purchase a capillaroscope, AND/OR do you have existing capillaroscopy images that you can upload? (You will NOT be reimbursed for the cost of a capillaroscope).
Are you able to complete the study in English?
Are you able to provide consent?
I understand and agree that: This is an eligibility form for the MIT CAPRIO clinical study. I am interested in becoming a participant. My participation in this clinical study is completely voluntary. My completion of this form does not guarantee nor force my participation in the CAPRIO clinical study.
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CAPRIO Eligibility Form

In order to participate, you will be required to have access to a capillaroscope (capillary microscope), be willing to purchase a capillaroscope, AND/OR have existing capillaroscopy images that you can upload.