• Thriving with Medical Devices - Submission Form

  • Hi there. Thank you for your interest in our project featuring people who are using medical devices and products and pursuing their passions!

    Please fill out the survey below ASAP. It should only take a few minutes. Once submitted, you may be contacted by a GENUINE Casting Team member for a follow-up self-recorded video to be viewed by our team and clients.

    If you experience difficulty taking this survey or have questions about the project, please contact GENUINE at submissions@genuinerp.com 

    If you have any questions about the information you provide to us, you can read GENUINE's Privacy Policy.

    Okay, let's get started!

  • Format: (000) 000-0000.

  • We'd like to learn more about you, so tell us a little about yourself.

  • Are you legally permitted / allowed to work in the United States?*

  • During this survey, we will be asking you about your medical history/health as it relates to using a medical device and/or product. Please select "I agree" below if you are willing to share information about your health as it relates to your diagnosis for the purposes of recruiting for this project.

    MEDICAL CONDITIONS

    Subject to your agreement to the waiver below, please share information regarding any medical conditions that you may have and are comfortable discussing publicly for potential projects. You acknowledge and understand that your personal health information may be protected from disclosure by the Health Insurance Portability and Accountability Act ("HIPAA") and other privacy laws. By selecting, "I agree" below, you consent to GENUINE electronically storing the personal health information that you disclose and reviewing it for purposes of contacting you about future projects for which you may be suited.

  • By selecting one of the options below, you acknowledge that you have read and understand the above statement.Type a question*

  • Now we'd like to learn about you, the medical devices and products you use, and how these devices and products help you pursue your passions.

  • Do you currently use a medical device and/or product?*
  • If requested, can you provide proof of use for your medical device and/or product? (Select best answers.)*
  • For which of the following do you currently use a medical device and/or product? (Select all that apply.)*
  • Since you use a medical device or product for cardiac issues, which do you currently use?*
  • Since you use a medical device or product for liver function or liver cancer, which do you currently use?*
  • Since you use a medical device or product for deep brain stimulation and/or pain management solutions, which do you currently use?*
  • Since you use a medical device or product for weight loss solutions, which do you currently use?*
  • Since you use a medical device or product for urology solutions, which do you currently use?*
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  • If it's easier, you can use the button below to take a photo of yourself:

  • Thank you so much. Just a few more questions and you'll be done.

  • What is your age range?*
  • What is your ethnicity/race?*

  • Our company and our client do not discriminate on the basis of gender identity or gender expression. In order to track the effectiveness of our recruiting efforts and ensure we consider the needs of our project, please consider the following questions optional.

  • What is your gender?
  • What are your gender pronouns?
  • As a part of the final selection process, would you consent to a Background Check?*
  • Please answer the following statements.*
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  • How did you hear about this project?*

  • GENUINE is always looking for people to share their stories and appear in paid advertising campaigns for major brands including American Express, Chipotle, and Walmart to mention a few.

    If you would like to hear about our latest casting opportunities, join GENUINE's mailing list.

    YOU ONLY NEED TO REGISTER ONCE, so if you receive our emails, please check, "I am already on the GENUINE Mailing List".  Thank you!

  • Would you like to be added to GENUINE's mailing list?*

  • Thank you so much for taking the time to answer all of our questions.

     Please click on the "Submit" button to complete your survey.

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