Clinical Trial Enrollment Form

Purpose: This form is used to collect essential participant information to determine eligibility and formally enroll candidates into a clinical research study. Please complete all applicable sections accurately.

Participant Information

Full Name: {fullName}

Date of Birth: {dateOfBirth}

Gender: {gender}

Contact Number: {contactNumber}

Email Address: {email}

Home Address: {homeAddress}

Emergency Contact Information

Contact Name: {emergencyContactName}

Relationship to Participant: {emergencyContactRelationship}

Phone Number: {emergencyContactPhone}

Study Eligibility Criteria Confirmation

Primary Diagnosis: {primaryDiagnosis}

Date of Diagnosis: {dateOfDiagnosis}

Meets Inclusion Criteria? {meetsInclusion}

Meets Exclusion Criteria? {meetsExclusion}

Insurance Information

Insurance Provider: {insuranceProvider}

Policy Number: {insurancePolicyNumber}

{#hasInsurance}

• Participant has valid insurance coverage.

{/hasInsurance}

{^hasInsurance}

• Participant does not have active insurance coverage.

{/hasInsurance}

Medical History

{#medicalConditions}

• {conditionName}: {conditionDetails}

{/medicalConditions}

Current Medications

Consent Information

Consent Form Signed? {consentSigned}

Date of Consent: {dateOfConsent}

Name of Study Coordinator: {studyCoordinator}

Summary Notes

{summaryNotes}

Investigator Approval

Investigator Name: {investigatorName}

Date of Approval: {investigatorApprovalDate}

Signature: _____________________________