Submit an Application Today To be eligible to participate in a clinical research study, simply submit an application. 1234 Have you previously submitted an application? Yes No Please call your recruiting office at 305-665-5151 to update your application with a recruiting team member or let them know of your interest in a study. Full Legal Name (As it appears on your Social Security Card)* First Middle Last Date of Birth* MM slash DD slash YYYY What is your gender?* Male Female Race*WhiteBlackAmer. IndianAsianAlaskaHawaiianPacific IslanderHispanic Ethnicity:* Yes No Height (Feet)*Height (Inches)*Weight (lbs.)*BMI*Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Phone #*Alternate Daytime #Work Phone #*By providing your mobile phone number, you are giving consent to send you text messages and/or automated calls regarding clinical research trials. Your cellular provider's message and data rates may apply. Please notify us immediately if you change mobile numbers or plan to provide your phone to another person.Email* Enter Email Confirm Email *By providing your email address, you expressly consent to receive emails from us.Are you able to read, write and comprehend without the help of others?* Yes No Women OnlyMethod of birth control:* Last menstrual cycle date:* MM slash DD slash YYYY Cycle Length (# of days):Menses Length (# of days):*Are you pregnant?* Yes No Plan to become pregnant?* Yes No Nursing or breastfeeding? Nursing Breastfeeding N/A Section BreakNo. of alcoholic drinks* Frequency* daily weekly monthly yearly Do you currently use any tobacco products?* Yes No What type? Menthol Cigarettes Non-menthol Cigarettes Chew E-vapor Cigars Loose/pipe Pouch Moist Snuff Dry Snuff Quantity (i.e., 1/2 pack, 1 can, 2 cigars, 1 pipe, etc.) Frequency daily weekly monthly yearly Has a QPS participant referred you?* Yes No Name of the participant who referred you First Last Select how you heard about QPS Miami* Radio TV Internet Search Social Media Email Print Word of Mouth Which study are you currently most interested in? Study #2308-SAD- Adults, 18-70 years, diagnosed w/ Type II Diabetes Study #2308-MAD - Adults, 18-70 years, diagnosed w/ Type II Diabetes Study #2309 - Adults, 18-70 years, diagnosed w/ Type II Diabetes I confirm that the information provided on this application is, to the best of my knowledge, complete and accurate. I confirm that I have read and expressly consent to provide my personal information to QPS Miami in accordance with these terms and conditions. I understand that this information will be used for the sole purpose of determining my eligibility to volunteer for a clinical research trial. I understand that QPS Miami will use its best efforts to treat my information provided in this registration form with security and confidentiality. The contact information I provide may be retained in a database owned by QPS Miami. I consent to be contacted by QPS Miami and its service providers via email, phone or text message and that standard usage rates may apply. I confirm that I am 18 years or overDate MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged. Δ
