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Participating in a study with MDS Pharma Services
Company

For more information about participating in a study in your area, please complete the information below.

Social Security Number ID Number
Last Name* First Name* Middle Name
Street Address*
City/Town*
State/Province
County
Zip Code/Postal Code*
Country
Phone #*
Occupation
Alternative Phone #
Alternative Phone Description
E-Mail Address*
Birth Date*
Age*
Sex*
Race
Availability for studies (check all that apply)
Weekdays Weekends Short Visits
Long Stays Summer Only Winters Only
Height*
Weight*
Frame Size
S M L
Do you smoke?*
Yes No
How much do you smoke
on a daily basis?
Start Date
Do you use tobacco products of any kind?
Yes No
Are you a former smoker?
Yes No
How much did you smoke per day?
When did you start?
When did you quit?
In the space below, please list any medication(s) you currently take on a regular basis. Be sure to include the name of the medication, when you began taking it, and what you take it for.  If you are not taking any medication, please type "none".*
In the space below, please include any questions or comments you may have.
 

* Indicates required field

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