Online Pre-Screening

· Pre-Screening Consent:

By completing this initial pre-screening form, you consent to ClinTrial collecting your answers, including your contact information. All information provided is held in strict confidence, and will only be shared with the ClinTrial Study Team. Upon your request, any records ClinTrial holds will be deleted.

Please check our Privacy Policy and Terms and Conditions.

· Pre-Screening Questionnaire:

This short survey helps determine whether you may qualify for a clinical trial for chronic wounds (Diabetic Foot Ulcers or Venous Leg Ulcers). Your answers are confidential and do not obligate you to participate.

What is your age? *

Under 21

21 or older

* You must be at least 21 years old to join this study.

Have you been diagnosed with either of the following? *

Type 1 Diabetes

Type 2 Diabetes

Chronic Venous Insufficiency / Venous Disease (CEAP classification)

Neither

Pregnancy *

Yes

Not applicable

Please pick the option that best fits your pregnancy status.

Are you able and willing to attend weekly study visits for up to 12 weeks at our clinical research site in Hamden, Connecticut? *

Yes

Are you willing to provide informed consent to participate in a clinical trial? *

Yes

Would you like a study coordinator to contact you to discuss your results and next steps? *

Yes

Congratulations, looks like you may be eligible for the trial. There's a few more steps before being accepted on.

Do you wish to continue your application?

Unfortunately, based on the details you have entered you are not eligible for this trial.

Clinical Trials have eligibility criteria to ensure the safety of participants and to help researchers achieve accurate and meaningful results. Not all trials have the same eligibility criteria and one in the future can be suitable for you.

Continue if you would like to be contacted about other trials in the future.

About you

First Name *

Last Name *

Date Of Birth *

Sex assigned at birth *

Male

Female

Why only these two? Our trials filter submissions based on sex assigned at birth. Intersex patients should select an option that best aligns with them.

Phone *

A way to contact you (mobile, home etc.)

Email *

The email address we use to contact you about your eligibility

Zip Code *

Country *

Email commitment *

Yes