IMIZ01 Patient Demographic Form

IMIC Research Patient Demographic Form

Para Español, seleccione del menú desplegable en la esquina superior derecha.
Patient Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Gender

MaleFemale
Preferred language

EnglishSpanishOther
Race

American Indian or Alaska NativeBlack or African AmericanNative Hawaiian or Pacific IslanderWhite
Ethnicity

Hispanic or LatinoNot Hispanic or Latino
Occupation
Social Security Number
Home Phone Number
Please enter a valid phone number.
Mobile Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you find out about us?

AdvertisementReferred by PhysicianReferred by someoneExisting patientOther
Emergency Contact
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Special Considerations
I understand that IMIC Research clinic will request medical records from my treating physicians and hospitals listed below.
Primary Care Physician
Phone Number
Please enter a valid phone number.
Other physicians, specialist
Please list name of hospital if you have been in ER or hospitalized in the last 5 years.
Are you willing to be entered in our research database and be contacted for future studies?

YesNo
*In the first visit we might collect blood/urine analysis, spirometry and/or other tests to see if you might qualify for a study.
I understand that I cannot be in 2 studies at the same time. (Initials)*
Digital Signature Authorization:*

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.
Signature*

Clear
Date

MonthDayYear
Date
Should be Empty: