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2440 Coral Wy, Coral Gables, FL 33145
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About You
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How Can We Reach You?
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Do you currently use any tobacco products?
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Final Questions
Are you able to read, write and comprehend without the help of others?
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Has a participant referred you?
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Select how you heard about us
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Consent
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I confirm that the information provided on this application is, to the best of my knowledge, complete and accurate. I confirm that I have read and expressly consent to provide my personal information to Clintex Research in accordance with these terms and conditions. I understand that this information will be used for the sole purpose of determining my eligibility to volunteer for a clinical research trial. I understand that Clintex Research will use its best efforts to treat my information provided in this registration form with security and confidentiality. The contact information I provide may be retained in a database owned by Clintex Research. I consent to be contacted by Clintex Research and its service providers via email, phone or text message and that standard usage rates may apply. I confirm that I am 18 years or over
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