Zel Skin and Laser Specialists

BE A VOLUNTEER

Thank you for your interest in clinical trials being conducted at Zel Skin & Laser Specialists. Please complete this form if you would like to be entered into the general database for clinical trials being conducted now or in the future. By completing this form in no way obligates you to participate in a clinical trial. You may modify or withdraw your information at any time by following the instructions listed below.

The information you provide will be made available to Zel. If your profile meets the needs of a particular study, a research coordinator from Zel will contact you directly via telephone or email. If it is determined that you would meet the criteria for a study, you will be required to make office visits to Zel located in Edina, MN. If a minor will be participating in a clinical trial, they must be accompanied by the parent or legal guardian and must provide proof of the relationship.

A parent or legal guardian may complete the form on behalf of a minor (under the age of 18 years). All contact information must be completed with the parent or legal guardian’s information (an asterisk will precede this information – *) All other database information will need to be completed regarding the minor. The following fields are required:

The following fields are required:

First Name:   Last Name:

Street Address:   City:

State:   Zip:

Phone (where you can be reached between 8 am and 5 pm):

Gender:     Date of Birth (mm/dd/yy):

Height:   Feet     Inches   Weight:

Are you in good general Health:

The remaining fields are not required, but may prove helpful in screening you for information for potential study matches. What specific dermatology illnesses or medical condition(s) do you have for which you are interested in volunteering?

Area of Interest #1:

Area of Interest #2:

Area of Interest #3:

Skin Type:

Do you use tobacco:

Regular Medications:

Current Medication List:   Phone (night):

Email:

Comments:

Are you submitting now to request an update to previously entered volunteer information?

Are you submitting now to request removal of information from the recruitment database?

Dr. Brian Zelickson, an internationally recognized expert in skin care,
treats patients from Minneapolis, St. Paul, Edina, Wayzata, Plymouth, St. Louis Park, Minnetonka
and other communities throughout Minnesota.

4100 west 50th street edina mn 55424 P 952–929–8888 F 952–929–9669
2007 Zel Skin & Laser Specialists. All rights reserved. Comments | Privacy
Page Last Updated 4–21–2008