See If You Qualify

This form will allow us to collect information about your health history. Your participation in completing this form is completely voluntary.

Your information will only be seen by researchers at Floridian Clinical Research. The information we collect will be kept private and used only for research studies at Floridian. Your health information will not be shared without your permission or except as required by law. Information collected on this form will be stored in our secured recruitment database. If you agree to being included in the recruitment database, you can request at any time that your name and information be removed.

If you qualify for a study at Floridian Clinical Research, you may be compensated for your time and travel.

By completing the information requested below you are permitting Floridian Clinical Research to retain this information in our files. If you prefer to speak to a screening coordinator in-person, please call us at 305-330-9977 and ask to speak to the screening department.