Sign Up - Avada Agency

SIGN UP FOR PATIENTS

Name *

Last Name *

Mobile Phone *

Address *

City *

Country *

Are you asymptomatic? *

Before COVID-19, indicate the chronic disease that you suffered (if you did not have, write NONE) *

Have you ever been hospitalized for COVID19? *

Do you currently have COVID19 symptoms? *

Date of last positive COVID-19 test

Application date

Doubts or Study Questions that I need to clarify (if you have no doubts, write NONE) *

Rules of participation

1. To participate, you must view the informative video contained on this website, you must carefully read the documents hosted on this website called Patient Information Sheet, and Patient Informed Consent. In addition, you must meet the inclusion criteria, and you must complete and submit this registration form, filling in all the required fields. Remember that your participation is free, voluntary, and you can leave the study when you consider it appropriate, without giving us any explanation for it.

2. INCLUSION CRITERIA

You must be between 18-75 years old
You must have symptoms consistent with COVID-19 after having close contact with a COVID-19 infected patient, or you have tested positive for coronavirus (COVID-19) polymerase chain reaction (PCR), or in the antigen test, from 40 days before the start of the study, or up to 10 days after it.

3. INFORMED CONSENT

I have been able to ask questions about the study, speaking with one of the researchers, or through email (cleofas@us.es).
I have been able to receive enough information about the study.
I understand that my authorization is voluntary.
I understand that I can withdraw from the study: // 1. When you want, of your own free will. // 2. Without having to explain my decision. // 3. Without this affecting my health care.
I freely grant my consent to participate in the study.
I give my consent to participate in this study.

AUTHORIZATION OF INFORMED CONSENT *

I have read the documents hosted on this website, called "PATIENT INFORMATION SHEET" and "INFORMED CONSENT FOR STUDY PATIENTS"

I AUTHORIZE my participation in the study, and I GIVE my informed consent

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