RCTS, Inc. Pediatric Application Form
RCTS, Inc. *3207 Esters Road * Irving, TX 75062 Phone: (972) 871-7578 Fax: (972) 871-7579 Email: recruiting@rctslabs.com
FOR RCTS USE ONLY: Panelist Number
Child's Name
*
First Name
Middle Name
Last Name
Address
*
Street Address
Apartment #/Street Address 2
City
State / Province
Postal / Zip Code
Child's Age (Please indicate years/months)
Child's Date of Birth
*
-
Month
-
Day
Year
Date
Sex
*
Male
Female
Ethnicity
*
African-American
Caucasian
Hispanic
Native American
Asian/Pacific Islander
Other
Parent's Name
First Name
Last Name
Parent's Panelist Number (If Applicable)
Parent's Home/Cell Phone Number
*
Please enter a valid phone number.
Parent's Work Phone Number
Please enter a valid phone number.
Parent's Email
example@example.com
PRODUCT USE: Does your child use any of the following products? (check all that apply)
MEDICAL HISTORY: Has your child ever been treated or diagnosed for any of the following medical conditions? Check all that apply:
*
Acne/Pimples
Allergies
Arthritis
Asthma
Athlete's Foot
Atopic Dermatitis
Cancer
Canker Sores
Dermatitis
Diabetes
Ear/Nose/Throat Problems
Eczema
Gastrointestinal Problems
Hayfever
Heart Problems
Hemorrhoids
Hepatitis
High blood pressure
HIV-positive
Hormone replacement
Kidney Problems
Liver Disease
Lung Disease
Lupus
Neurological Problems
Psoriasis
Rosacea
Sexually Transmitted Disease
Thyroid Disease
Ulcers
Other
NONE
Other
If you checked any of the above other than "None," please explain below.
List any medications your child takes regularly (including antihistamines and antibiotics) and the reason(s) why. If the child is not taking any medications, please write "NONE."
Is your child allergic or sensitive to any of the following? Check all that apply:
*
Fragrances
Soaps
Cosmetics
Detergents
Antiperspirants
Deodarants
Foods
Medicines
Preservatives
Adhesives/Bandaids
Suntanning Products
Bath Products (oils, herbals, etc.)
Other
None
If you checked any of the above, other than "None," please explain below.
Has your child ever participated on a test panel at RCTS before?
*
Yes
No
Is your child currently participating in a clinical study at RCTS or any other testing facility?
*
Yes
No
If "yes" to the above question, please type the name of the facility.
To the best of my knowledge, the above information is true and I consider my child to be in general good health.
*
Yes
No
Signature
*
Date
*
-
Month
-
Day
Year
Date
Referred By:
If you were not referred by someone, how did you hear about us?
RCTS Website
Walk-In
Internet Search
Social Media (Facebook, Instagram, Twitter)
Other Testing Facility
Flyer
Other
Submit
Should be Empty: