Research Clinic Trial Screener

 

Please fill out this from to verify your eligibility for a Clinical Trial.

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Contact Information

FirstName: *

LastName: *

Date of Birth: *  

Phone: *

Email: *

Have you had a stroke, heart attack OR surgery on your leg arteries? *

Yes

No

Do you have Liver Disease? *

Yes

No

Do you have Kidney Disease? *

Yes

No

Do you have an LDL level greater than 80 and/or a Total Cholesterol level greater than 170? *

Yes

No

Are you currently taking a statin medication to lower your cholesterol? *

Yes

No

By clicking on submit, you are giving Aspirus Research Clinicians the permission to view only the pertinent parts of  your medical record to verify you are an appropriate candidate for this study.