OpenCures Customer Intake
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Email *
First Name *
Middle Name
Last Name *
Address 1
Address 2
City
State/Prov
Country
Zip Code
Phone Number
Date of Birth *
MM
/
DD
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YYYY
How much do you know about biology?
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Gender
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Weight
Weight Units *
Height (e.g. 72 instead of 6ft)
Height Units *
Blood Type
Diagnosed with
Date Diagnosed
MM
/
DD
/
YYYY
Diagnosis Details
Health Interests
Referred by
Group Name
Hours Fasted *
Food in past 10hrs
π•―π–Žπ–˜π–ˆπ–‘π–†π–Žπ–’π–Šπ–—
OpenCures is a scientific services company specializing in helping you perform Self-Directed Research by helping you identify and access cutting-edge research tools and educational material to give you insight into your biology and health. Β The samples and results of the assays obtained through OpenCures are owned by you. Β OpenCures makes no representations of the suitability of the data for a particular purpose and you are entirely responsible for their interpretation and any actions you may take as a result of that interpretation although OpenCures may assist in your self-education by providing research materials based on peer-reviewed research. Β 

Please read our full disclaimer before consenting to use our services.

https://docs.google.com/document/d/1VuSa1wzCvqopIHX7_HLSas_1UI6X5iD1NasX1FyI0E0
General Consent
I consent to:
Β - The collection of biological samples (or biospecimens) for assays that I order.
Β - The shipment of my biospecimens to assay/testing providers as necessary.
Β - The storage of the results of such assays/tests in a private profile on our online platform.
Β - The storage of my biospecimens in the OpenCures BioBank.

NOTE: General Consent is necessary to provide service. Β 

General Consent *
Sharing (Optional)
πƒπšπ­πš 𝐚𝐧𝐝 𝐁𝐒𝐨-π’π©πžπœπ’π¦πžπ§ π‚π¨π§π¬πžπ§π­ (𝐎𝐩𝐭𝐒𝐨𝐧𝐚π₯)

I consent to:

Anonymously share my data and bio-specimens to speed the development of cures for disease.

Sharing *
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