Patient Participant Contact Information

Thank you for taking the time to share your contact information and health conditions with LaGrippe Research. We will keep this information in our secure database and contact you for a future project that requires your opinions and experiences. You have the right to withdrawal from our database at any time.

We look forward to working with you!

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* 1. Patient Registration

First Name

Last Name

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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* 2. Do you suffer from any medical conditions?

Yes (please list the medical conditions you have been diagnosed with by a physician)

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* 3. Do you have a family member or friend that you care for that has been diagnosed with medical conditions?

Yes (please list the medical conditions your loved one has been diagnosed with by a physician)

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* 4. How did you hear about us?

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* 5. What is your birth month and year?

Birth Month

Birth Year

Current Age

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* 6. What is your gender?

Male

Female

Other (please specify)

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* 7. What is your ethnicity? (Please select all that apply)

Caucasian or White

African American or Black

Hispanic or Latino

Asian or Asian Indian

Middle Eastern

Pacific Islander

Other (please specify)