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Patient Recruitment Form (15 - 24 Years)
This form can be filled by participants aging from 15 years up to 24 years.
14
Questions
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1
Name
*
This field is required.
First Name
Last Name
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2
Date of Birth
*
This field is required.
-
Date
Year
Month
Day
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3
Gender
*
This field is required.
Male
Female
Prefer Not To Say
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4
Email
*
This field is required.
example@example.com
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5
Phone Number
*
This field is required.
Please enter a valid phone number.
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6
Do you suspect that you have been exposed to COVID in last 10 days?
*
This field is required.
Exposure is: if you live with or have been in contact with someone who has COVID-19
Yes
No
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7
Are you experiencing any of the COVID-19 symptoms in the past 48 hours?
*
This field is required.
COVID-19 Symptoms: fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea
Yes
No
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8
Do you suspect any other infection that could be causing you covid-19 symptoms?
*
This field is required.
Yes
No
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9
Will you be comfortable in attending a short telemonitoring (zoom) session for your specimen collection with SDI Labs?
*
This field is required.
Yes
No
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10
Are you comfortable using mobile phone applications?
*
This field is required.
Applications like: Facebook, Email, Google fit, Apple health
Yes
No
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11
This study requires you to do the Anterior Nares specimen collection. Are you comfortable with this procedure?
Click here
to see the picture
*
This field is required.
Yes
No
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12
Are you a severely ill patient where urgent support is needed?
*
This field is required.
Yes
No
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13
Consent
*
This field is required.
I agree to the terms and conditions and give my consent for the same. If you'd like to read more on our study protocol
click here
. Why are we asking for this?
click here
. We are currently sending out 1 free antigen test kit and
1 RT-PCR
to patients to use during the study and one RT-PCR voucher for later as a gift from us. These kits are lower nasal swabs, so no brain tickle or throat swab. Additionally, we are offering a one-time $20 gift card as well as an additional test for future use as a thank you for participating in our study.
Clear
We are so glad to have you as a part of our study.
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14
Please schedule your appointment to visit the lab
*
This field is required.
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