Chlamydia and Gonorrhea Clinical Trial - Find Out If You Pre-Qualify

Chlamydia and Gonorrhea Clinical Trial

Thank you for your interested in our study on chlamydia and gonorrhea. Fill out the information below and one of our team members will contact you soon to let you know if you qualify to take part in the study.
Date of Birth *

Month Day Year
Date
Do you have a history of Chlamydia or Gonorrhea in the last 16 weeks with documentation? *

Yes No
Do you have the following risk factors? *

Are you between the ages of 18 to 24? Have you had a new sex partner within the past 12 weeks? Do you have more than 1 current sex partner? Do you know if your current sex partner has multiple partners? Does your partner have a known sexually transmitted infection? If you're in a mutually monogamous relationship has there been inconsistent condom use?
Are you pregnant or breastfeeding? *

Yes No
Have you had vaginal sexual intercourse with a male partner at least 3 times per month in the previous month and do you expect to have vaginal sexual intercourse regularly for the duration of the study? *

Yes No
Do you have a history of drug or alcohol abuse in the last 12 months? *

Yes No
Name *

First Name Last Name
Email *
example@example.com
Phone Number *

Area Code Phone Number
Should be Empty: