Please
complete the questionnaire below so that we may determine
if you qualify to participate in any of our current or planned
research studies.
If you wish, you may select the "Submit"
option when you are done to send this form to us by e-mail.
If you do not wish to e-mail your responses,
you may print your completed form directly from your browser
and mail or fax it back. Our mailing address is: Colorado
Allergy and Asthma Centers, P.C., 125 Rampart Way, Suite #150,
Denver, CO 80230. Our fax number is (720) 858-7530.
If it appears that you are a good candidate
for an upcoming study, we will ask you to schedule a short
visit (15-30 minutes) to measure your lung functions and determine
the study(ies) for which you may be eligible. If you are not
currently eligible for a study, we will keep your information
in our database until an appropriate study becomes available
unless you tell us you want your information deleted.
Any information you provide is protected by the Health
Insurance Portability and Accountability Act (HIPAA) of 2001.
Your information will not be sold or given to any party outside
Colorado Allergy & Asthma Centers, PC.
Thank you for your time and interest in
completing this questionnaire. We look forward to meeting
and working with you!
|
