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Screening Form
Please complete the screening form below
First Name
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Last Name
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Phone Number
Email Address
Gender
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Male
Female
Date of Birth
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Are you or a loved one diagnosed or suspected to be diagnosed with focal epilepsy?
Yes
No
Do you have any unstable medical conditions?
Yes
No
Do you have the ability to travel to NIH in Bethesda, Maryland for this study (travel arrangements can be made for you)?
Yes
No
You agree that BuildClinical may provide your personal information to the research site to help determine if you are eligible for this study. Please refer to BuildClinical’s Terms of Service and Privacy Policy for more information.
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