Clinispan Health Platform Signup

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Email *

First Name *

Last Name *

Phone Number *

City *

State *

Postal Code *

What is your age range *

Younger than 16 years of age

16-19

20-40

Older than 40 years of age

Race/Ethnicity *

Multi-race

White or Caucasian

Black or African American

Hispanic or Latinx

American Indian or Alaskan Native

Asian or Pacific Islander

Other:

Date of Birth *

YYYY

What is your sex? *

Male (Assigned at birth)

Female (Assigned at birth)

Are you in close contact with at least one child weekly *

Yes

Are you currently pregnant or planning to become pregnant within the next 9 months?
*

Yes

Have you participated in a clinical trial within the past month?
*

Yes

Have you participated in clinical research before?
*

Yes

How interested in participating in in-person research opportunities near you that you may qualify for?
*

Disclaimer:

By submitting this form you give CliniSpan Health permission to use the information to create an account on the CliniSpan Health platform on your behalf and to prequalify you for studies that you may be a good fit for. (Being prequalified for a study DOES NOT mean you are required to participate). Studies can compensate up to $10,000+ based on study criteria.

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This form was created inside of CliniSpan Health.