Houston Study -Diabetes October 2018

Introduction Section

Plaza Research Houston is conducting a study with consumers ages 18 and older on the topic of Diabetes. The discussion takes place on Sunday, October 14th, Monday October 15th, and Tuesday, October 16th, 2018, time varies throughout the day and evening. If you qualify, and are chosen to participate, you will receive $599 for a 6 hour study.
**Proof may be required in order to participate if chosen**

Please answer the questions below. If you look like a match, we will contact you by telephone.

**Due to the large response to our surveys, we are only able to contact those that look like a match. Please continue to answer future studies, as you may be a match to those.

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* 1. Please provide us with the following information. We will be contacting you by telephone if you seem like a match.

First Name *

Last Name *

City/Town

Email Address: *

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* 2. What is your Zip Code?

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* 3. What is your primary phone number?

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* 4. Alternate Contact number

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* 5. What is your age?

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* 6. What is your date of birth?

Date

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* 1. Please provide us with the following information. We will be contacting you by telephone if you seem like a match.

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* 2. What is your Zip Code?

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* 3. What is your primary phone number?

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* 4. Alternate Contact number

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* 5. What is your age?

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* 6. What is your date of birth?

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* 7. What is your gender?