Dr. Bhandari - pre-screening questionnaire

Pre-screening Questionnaire

Please fill out this form and we will get in touch with you shortly.
Your Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Your E-mail Address*
Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Have you been diagnosed with ulcerative colitis?*

YesNo
Do you take medicine to treat your ulcerative colitis?*

YesNo
Have you failed to respond to any the following: Steroids (prednisone), Remicaide (Infliximab), Humira (Adalimumab), Simponi (Golimumab) or Entyvio (Vedolizmumab)?*

YesNo
Are you interested in participating in a clinical study, for a new treatment for ulcerative colitis?*

YesNoNot sure
Comments regarding your ulcerative colitis
Enter the message as it's shown*
Should be Empty:

Pre-screening Questionnaire