Register for a Clinical Study | Participants Kansas

What study are you interested in? *

First Name *

Middle Initial *

Last Name *

Is the participant under the age of 18? *

Yes

Date of Birth *

Month

Day

Year

Gender *

Street Address *

City *

State *

Zip *

Primary Phone *

Secondary Phone

Height (feet) *

Numbers only, example 5.6

Weight (pounds) *

Numbers only, example 150

Are you currently taking any medications? *

Yes

Do you currently smoke or use any form of nicotine? *

Yes

How did you hear about us? *

Would you like to be contacted for future study opportunities? *

Yes

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