Doylestown Hospital
595 West State Street, Doylestown, PA 18901 (215) 345-2200
V.I.A. Health System
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Online Questionaire


Medical Research Study - Participant Survey

Thank you for your interest in volunteering for Doylestown Hospital Medical Research studies. This form is to be used if you would like to be added to the general database of volunteers for possible participation in any research study, now or in the future. Filling out this form does not obligate you to participate in any study, but may result in one or more contacts by phone or e-mail assessing your interest and suitability for clinical trials.

You may modify or withdraw your information at any time by resubmitting this form with your full name, address, phone number and date of birth, and by answering the last two questions in the form.

The information you provide will be made available to researchers who will contact you directly should your profile meet the needs of a particular study. Participation in clinical research studies is voluntary and requires visits to Doylestown Hospital.

Participants must be 18 years of age or older.

* Indicates required information

Please provide the following information to help us best serve you.

First Name *
Middle Initial *
Last Name *
Email *
Street *
City *
State *
Zip *
Phone *
Year of Birth (yyyy) *
Gender *

1. *
Please list the conditions or diseases a doctor has told you that you have. This information is optional, but providing it may help researchers match you with studies that fir your personality.
2. *
Please list all medications (including over-the-counter drugs) that you are currently taking.
3. *
Please list any additional health history information (diagnoses or conditions, hospitalizations, surgeries, etc.).
4. *
Please include any additional comments here.
5. *
Have you ever been a patient at Doylestown Hopsital?
      
6. *
Have you ever participated in previous Doylestown Hospital research studies?
      
7. *
Are you updating personal information you previously entered for this registry?
      
8. *
Are you submitting a request to remove your personal information from this registry?
      

 
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