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Employees Only

The following questions are completely confidential; they will be used solely for the purpose to determine your initial eligibility for a study which you elect to be considered for. Should you elect to participate in a trial we will schedule an appointment with a doctor to explain the details of the study completely. At that point, if you are still interested in participating, we can begin the initial assessments to verify your eligibility (such as a physical exam, blood draw, vital signs, ECG, etc.). 

Contact Information
Name
Address
Home Phone
Work Phone
Mobile Phone
Study Eligibility Questions
Study you are interested in?
Date of Birth
Gender	Male Female
Are you 18 years of age or older?	Yes No
For Females of Child-bearing potential– Are you pregnant, planning to become pregnant or breastfeeding?	Yes No
Do you have any medical problems that require ongoing and current medical attention?	Yes No  If yes, please specify
Do you have any allergies?	Yes No  If yes, please specify
Are you on any prescription medications (including oral, patch, or injectable)?	Yes No
Have you suffered any trauma, fracture, major surgery, or biopsy of an organ within the last 3 months?	Yes No
Do you use illicit drugs or drink alcohol to excess?	Yes No
Have you participated in another trial of an investigational drug or device within the past 30 days?	Yes No
May we keep your name and contact information to inform you of future studies in which you may be interested?	Yes No

Mercy Hospital
3663 South Miami Avenue
Miami, Florida 33133
(305) 854-4400