PERSONAL INFORMATION

Name Date of Birth MM/DD/YYYY

Address  Apt  Age MaleFemale

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Phone: Home   Work  

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Ethnic Origin:  CaucasianAfrican AmericanHispanicAsianNative AmericanOther

EMERGENCY INFORMATION

CONTACT PERSON 1

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Phone

Address  

City State Zip  

CONTACT PERSON 2

Name  

Phone   

Address

City State Zip  

Complimentary Services

Patient Consent

I understand that I will be receiving marketing text messages, emails, and phone calls from Zenos Clinical Research staff. I understand that I am providing consent for optional complementary services that may be offered by Zenos Clinical Research (in its sole and absolute discretion) or that I have requested and as agreed to by Zenos Clinical Research. I also understand that the medical conditions, medications, and demographics that I have provided will be added to the Zenos Clinical Research patient database. By signing below, I agree that I have reviewed and agree to the Zenos Clinical Research privacy policy attached to this consent form, and that I acknowledge the opt out provisions set forth in the privacy policy.

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Signature Certificate

Document name: Site Registration/Consent Form

Unique Document ID: 529a54bd4ece1b2c29c74974e7189bb8ff16cd7f

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Timestamp	Audit
December 9, 2021 12:32 pm CDT	Site Registration/Consent Form Uploaded by Tony Louis - [email protected] IP 76.214.69.88
May 25, 2023 12:19 pm CDT	Zenos Recruitment - [email protected] added by Tony Louis - [email protected] as a CC'd Recipient Ip: 76.214.69.88
September 27, 2023 6:28 pm CDT	Zenos Recruitment - [email protected] added by Tony Louis - [email protected] as a CC'd Recipient Ip: 76.214.69.88

This audit trail report provides a detailed record of the online activity and events recorded for this document.

https://zenosclinicalresearch.com/

Audit Trail Serial# 052ed4fdef9bb822582422feb637b2fb