Complete our prescreening questions
to see if you may qualify for one of our clinical studies or research projects.
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All information is kept strictly confidential and is HIPAA protected.

We will contact you to let you know whether or not you qualify. If you do not qualify at this time, by submitting this form, you are giving us permission to contact you in the future about the studies or research projects for which you may be eligible.

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Have you had a test for COVID-19 and tested positive?
Do you live in a household with someone who just tested positive for COVID-19?
Do you work in a field with increased chances of exposure to COVID-19?
List all symptoms you are currenlty experiencing:
How long have you been experiencing above symptoms?
Check all conditions that apply to you that put you at higher risk of complications from COVID infection:
Let us know of the conditions that apply to you or the diseases you have been diagnosed with:
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Thanks for submitting! We will get back to you soon to let you know if you qualify for any of the studies or research projects we currently have.