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Research Interest Form
Thank you for your interest in our clinical research program. Please complete the information below and we will contact you during our next enrollment period if we feel you may be candidate for a clinical study.
1.
What is your age range?
18-30
31-44
45-64
65 or older
2.
What studies would you be interested in?
Hand Filler
Face Filler
Neurotoxin
Skin Care
Laser
All of the above
3.
Which description best fits your skin?
Light, pale white. Always burns, never tans.
White, fair. Usually burns, tans with difficulty.
Medium, white to olive. Sometimes mild burn, gradually tans to olive.
Olive, moderate brown. Rarely burns, tans with ease to a moderate brown.
Brown, dark brown. Very rarely burns, tans very easily.
Black, very dark brown to black. Never burns, tans very easily, deeply pigmented.
4.
Clinical research studies require visits within certain timeframes. It is very important that if you are selected for a study that you keep every appointment. Will your schedule be able to accommodate visits agreed upon?
Yes
No
5.
Full Name
6.
Phone Number
7.
Email
