Brain Edge Clinical Study Participant Application
Please fill out this form to participate in the Brain Edge Clinical Study. 
Consent to have your personal information collected. *
This survey will ask you to provide some of your personal information, including demographic information and some of your medical history and health status.  This information is being collected to ensure that all study participants are healthy enough to participate in study activities.  Any information you provide is considered confidential and will not be used for commercial purposes nor will it be shared with third parties. 
Filling out this survey does not guarantee your enrollment in this study.  
Next
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report