COPD Clinical Trial
Thank you for your interested in our study on Chronic Obstructive Pulmonary Disease. 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
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Have you been diagnosed with COPD within the past 12 months?
*
Yes
No
Are you a current or ex smoker?
*
Yes
No
If you are an ex smoker have you quit within the past 6 months?
Yes
No
Do you currently use an inhaler as part of your current maintenance therapy?
Yes
No
Submit
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