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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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Teen First Name
Teen Last Name
What city do you live in?
What state do you live in?
Select
Alabama
Alaska
Arizona
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 between the ages of 13 and 17 (inclusive)?
Yes
No
Does your teen have any conditions or factors that would make it unsafe for him/her to undergo an MRI scan? This could include non-removable metal objects in the body (such as braces)
Yes
No
Are you and your teen willing and able to come in for one in person study visit on campus?
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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BCFS00617