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Screening Form
Please complete the screening form below and our team will be in touch. Thank you!
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First Name
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Last Name
Phone Number
Email Address
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Gender
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Other
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Date of Birth
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What city do you live in?
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What state do you live in?
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What category best describes you?
American Indian or Alaska Native
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Have you been diagnosed with Ulcerative Colitis?
Yes
No
Are you currently receiving treatment/medication?
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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BCFS00995
