Bladder Pain Research Participant Information Form

Bladder Pain Research Participant Information Form - BCH

What is your age?*

Select one. Please note, you must be 18 years old or older to participate in this survey and study. If you are under 18 years old, please consult with a guardian.

Select

Which best describes your current situation?*

Please select all that apply.

Select or enter value

Interest in participating in an IC/BPS study*

Are you interested in signing up for the IC/BPS study at Boston Children’s Hospital? Select one. Selecting "Yes" or "Maybe" will promot the request for your contact information.

Yes, I would like to sign up now

Maybe, I would like more information

No, I would not like to participate

First Name*

Last Name*

Phone Number

Phone

Email Address*

Note

Send me a copy of my responses

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