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Clinical Trial Application
Please fill out the form below
Medtrace Rapid-Water-Flow study
First Name
Middle Name
Last Name
Date Of Birth (ex 01-DEC-1963)
Email
Mobile Phone
Do you have any known history of cardiac disease?
Yes
No
Have you undergone any diagnostic procedures for coronary artery disease?
Yes
No
Do you currently have any cardiac procedures planned for the near future?
Yes
No
Please check any below criteria that may apply to you.
Severe COPD
Chronic Asthma
Second- or Third-degree AV block
On Sildenafil or oral Dipyridamole
On another clinical trial
N/A - none of these apply to me
Submit