Customer Preview
Screening Form
Please complete the screening form below and our team will be in touch. Thank you!
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First Name
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Last Name
Phone Number
Allowed Countries:
US
United States (+1)
Email Address
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Gender
Male
Female
Other
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Date of Birth
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What city do you live in?
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What state do you live in?
Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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Select all of the following that best describes you:
American Indian or Alaska Native
Asian
Black or African American
Hispanic, Latino, or Spanish origin
Middle Eastern or North African
Native Hawaiian or Other Pacific Islander
White
Have you been diagnosed you with Graves' disease, an autoimmune condition that causes an overactive thyroid?
Yes
No
Are you currently taking medication for Graves' disease?
Yes
No
Have you ever received radioactive iodine treatment or had all or part of your thyroid removed?
Yes
No
Unsure
Do any of the following apply to you?
I have severe thyroid eye disease that needs steroid treatment or urgent medical care.
I have an enlarged thyroid (goiter) that makes it difficult to swallow or breathe.
I have had confusion or a fever during an episode of overactive thyroid that was not explained by another cause.
I have significant heart disease.
I have atrial fibrillation, an irregular heart rhythm.
I have a fast heart rate that needs urgent treatment.
I have an active autoimmune condition other than Graves' disease.
I have an immune deficiency.
I have uncontrolled diabetes.
I have a current or long-term infection, such as HIV, hepatitis, or tuberculosis.
None of these apply.
Would you be willing to learn more about the study and, if you're eligible and choose to participate, stay at the clinic in Las Vegas, NV for at least 48 hours after receiving the study treatment and attend the follow-up visits?
Yes
No
Maybe
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What is the best method to contact you?
Call
Text
Email
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What is the best time of day to contact you?
Early Morning (8AM-10AM)
Late Morning (10AM-12PM)
Early Afternoon (12PM-3PM)
Late Afternoon (3PM-5PM)
Evening (5PM-7PM)
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Do you consent to receiving text message communications from our study team?
Yes, opt-in: Send me updates via text. I understand that message and data rates may apply and that I can opt out at any time by replying 'STOP'
No, opt-out: Use email or phone calls only
You agree that BuildClinical may provide your personal information to the research team conducting this study to determine whether you are eligible for study participation. BuildClinical may also use your information to inform you about other research opportunities that may be relevant to you. Please refer to BuildClinical's Terms of Service and Privacy Policy for more information.
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Eligibility Criteria:
The eligibility criteria listed here is only visible in the Customer Preview version of the form. Eligibility will not be visible for potential participants filling out the form.
If
ALL
of these conditions are TRUE:
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