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Research Patient Questionnaire
Clinical Research Department
* Indicates required question
Email
*
Record my email address with my response
First Name
Your answer
Last Name
Your answer
More than 18 years of age?
Yes
No
Clear selection
Which clinical trial (s) you wanted to participate?
Rheumatoid Arthritis
Lupus
Psoriatic arthritis
Polymyositis
Sjorgen's syndrome
Lupus Nephritis
Other:
Which location (s) is closer to you?
Rockford
Elgin
Clear selection
What is the best way to contact you?
Telephone
Email
Clear selection
Telephone number?
Your answer
Email address
Your answer
Option 1
Clear selection
We appreciate your time in completing this survey. Thank you, and we look forward to speaking with you!
Send me a copy of my responses.
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