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Clinical Research Volunteer Form

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Clinical Research Volunteer Form

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Personal Information

All fields marked with * are required.

We appreciate your interest in our research studies. Listed below is a generalized questionnaire that will help us to determine whether or not you will be a good candidate for the study/studies in which we are enrolling at the present time. The information you provide will be used for the sole purpose of determining your participation for studies listed below, as well as studies in the future.

*First Name:

*Last Name:

*Phone:

*Email:

*Age:

*Gender:

Male

Female

*Are you able to adhere to a flexible weekday schedule?

Yes

*Are you a current patient of The Practice of Brian S. Biesman, M.D.?

Yes

While research studies are great for many people, there are some restrictions that participation may require. Please review the following statements and consider if participating in a research study is right for you.

*Are you currently taking any prescription medications?

Yes

*Please list all major medical problems:

*Currently pregnant and/or nursing?

Yes

*Are you a smoker?

Yes

*Have you participated in any prior studies at our office?

Yes

*Have you had prior cosmetic surgery?

Yes

*Have you had any cosmetic injections (i.e.Juvederm,Restylane,Botox)?

Yes

*Most of our research study protocols require a minimum of 6 months since most recent botulinum toxin injections and 12 months since most recent filler injections:

I HAVE had a Botulinum Toxin Injection in the last 6 months

I HAVE NOT had a Botulinum Toxin Injection in the last 6 months

I HAVE had a Filler Injection in the last 12 months

I HAVE NOT had a Filler injection in the last 12 months

*Have you had previous cosmetic laser treatments?

Yes

*Describe your skin type:

Type I always burns, never tans (palest; freckles)

Type II usually burns, tans minimally

Type III sometimes mild burn, tans uniformly

Type IV burns minimally, always tans well (moderate brown)

Type V very rarely burns, tans very easily (dark brown)

Type VI Never burns (deeply pigmented dark brown to darkest brown)

Study of Interest:

Please indicated if you are interested in being considered for a specific clinical trial.

While research studies are great opportunity for many people, there are some restrictions that your participation may require. Please review the following statements and consider if participating in a research study may be right for you.

Clinical trials often require inclusion of a diverse patient population. While this question is optional, the information helps us determine which trial might be of greatest interest to you.

Ethnic Origin: Please specify your ethnicity.

White

Hispanic or Latino

Black or African American

Native American or American Indian

Asian / Pacific Islander

Other

Please keep in mind that each study has very specific protocol guidelines and inclusion/exclusion criteria. Please be patient and refrain from calling the office to inquire further about the study enrollments. As we enroll for each study, we will contact you only if you meet the protocol required for that specific study.

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Clinical Research Volunteer Form

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