Immunotherapy Questionnaire

Immunotherapy Questionnaire

People currently using subcutaneous (under the skin) immunotherapy injection.
Hi there. Thank you for your interest in our project featuring adults using Subcutaneous Immunotherapy Injection.

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 to provide you with the next steps if selected.

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!
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
City State

Street Address

Street Address Line 2

CityState

Zip Code
Zip Code
Support Person's Name (if applicable)

First NameLast Name
Support Person's Phone (if applicable)
Please enter a valid phone number.Format: (000) 000-0000.
Support Person's Email (if applicable)
example@example.com

During this survey, we will be asking you about your medical history/health as it relates to your diagnosis of cancer and treatments. 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.

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

Should you have any questions, please call us at 212-966-3211 x 2 or submissions@genuinerp.com

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