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Apply for a study.

Fill out this form and a coordinator will contact you
within 48 hours to see if you qualify for a study.

Study Application Form

First Name

Last Name

Email

Phone/Mobile

Travel agreement

Good Time to Call

Study Application For:

Are you regularly using inhaled steroids? (Example - Advair, AirDuo Respiclick, Breo Ellipta, Dulera, or Symbicort)

Yes

No

Have you had a physician diagnosed asthma for at least 1 year?

Yes

No

Do you smoke?

Yes

No

How often do you use your rescue inhaler?

Do you have any other serious respiratory issues? (Example – COPD, Bronchiestasis, Tuberculosis)

Yes

No

Have you been diagnosed with CD for at least 3 months?

Yes

No

Have you had an inadequate response or intolerance to conventional treatment?

Yes

No

I'm Not Sure

(Aminosalicylates, corticosteroids, methotrexate, 6-mercaptopurine, biologics)

Do you currently have symptoms defined by rectal bleeding and increased stool frequency?

Yes

No

I'm Not Sure

Does your child have 2 or less bowel movements a week?

Yes

No

I'm Not Sure

Are you willing to stop your child’s current laxative/enema treatment?

Yes

No

Does your child have celiac disease, lactose intolerance, or a cow milk allergy?

Yes

No

I'm Not Sure

Does your child have a history of migraines for at least 6 months?

Yes

No

I'm Not Sure

Does your child have 1-14 migraines a month?

Yes

No

I'm Not Sure

Has your child tried at least one oral medication for treatment?

Yes

No

Have you been diagnosed with UC for at least 3 months?

Yes

No

Have you had an inadequate response or intolerance to conventional treatment?

Yes

No

I'm Not Sure

Aminosalicylates, corticosteroids, methotrexate, 6-mercaptopurine, biologics

Do you currently have symptoms defined by rectal bleeding and increased stool frequency?

Yes

No

I'm Not Sure

What illnesses do you have that you are willing to participate in a clinical trial for?

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