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Panelist Profile Form

General Panelist Information

First Name *

Last Name *

Gender *

Date Of Birth *

Cell Phone *

Alternate Phone

Email Address *

Address *

Address 2

City *

State *

Zip *

Height (in inches) *

Weight (in pounds) *

Ethnicity *

Race *

Emergency Contact Name *

Emergency Contact Phone *

Emergency Contact Relation *

Ob-Gyn and Birth Control Information (Female-Born Panelists Only)

Are you sexually active?

Panelist Medical Background

Dental:

Dental Implants

Dry Mouth

Missing Teeth

Periodontal Disease

Removable Dentures

Hair and scalp conditions:

Alopecia

Balding / Thinning

Dandruff / Seborrhea

Photosensitivity – After sun exposure you have had these reactions:

Bumps / Hives

Blisters

Loss of Pigment / Lightening

Rash

Uneven Redness

Use of body hair removers:

Face (chin, lip, brow)

Leg

Bikini

Are you currently using any of the following medications?

Antibiotics

Antihistamines (e.g. Allegra, Benadryl, Zyrtec)

Blood Thinners

Insulin

Topical Medications (e.g. medicinal creams, lotions)

Non-Steroidal Anti-Inflammatories (e.g. Advil, Aleve, Bayer, Naproxen)

Steroids / Steroidal Inhaler

Immunosuppressant / Immunomodulator / Chemotherapy

Have you had any medical procedures in the last 12 months? *

Yes

Have you had any chemical or physical treatment procedures in the last 12 months? *

Yes

Miscellaneous and Disclaimer

By submitting this information to Eurofins CRL you are certifying that all the above information is up to date and accurate. If any information is found to be incorrect, or missing, you could be disqualified from participating in studies with Eurofins CRL in the future.

Contact Info

Eurofins | CRL, Inc.

Phone Number:

336-725-6501

Office:

411 W. 4th St., Suite 100 and 101 Winston Salem, NC 27101 USA

Email:

info@suncarelab.com

News

Eurofins CRL COVID-19 Update
June 29, 2020
Virtual Mutt Strut May 15, 2020
June 29, 2020
Eurofins | CRL Response to COVID-19 [Update]
March 23, 2020

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