Skip to content
Screening Form
Please complete the screening form below and our team will be in touch. Thank you!
Displayed
First Name
Displayed
Last Name
Phone Number
Email Address
Hidden
Gender
Male
Female
Hidden
Date of Birth
Teen First Name
What state do you live in?
Select
Alabama
Alaska
Alaska
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Is your teen within the age range of 13 and 17?
Yes
No
Do you and your teen speak English?
Yes
No
Is your teen taking any medications for weight loss?
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.
Displayed
Captcha
Submit
Terms of Service
Privacy Policy
Terms of Service
Privacy Policy
Tagged
BCFS00612
