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Carver College of Medicine



    

Panic Study Registration

Please read and fill out the form:
Information gathered on this form is sent to the research staff via unsecure means - more like sending a postcard than a letter in an envelope. If you are concerned about confidentiality, please call our office or print out the form and send it by mail to: William Coryell, MD, Psychiatry Research-MEB, University of Iowa, Iowa City, IA 52242. Thank you.

Preliminary Study Information:

The affected person(s) in my family is/are: (check all that apply)
Myself   Brother   Sister
Mother   Father   Child
Other

How many brothers and/or sisters do you have?  

How many children do you have?  

Is your mother living?   YES NO

Is your father living?   YES NO

I agree to have one of the research staff contact me about the research studies.

FIRST NAME:  
MIDDLE INITIAL:  
LAST NAME:  
TITLE:   Mr.   Mrs.   Miss
ADDRESS:  
CITY:  
STATE:  
ZIP CODE:  
TELEPHONE:  
E-MAIL:   Optional

COMMENTS:

 

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University of Iowa Hospitals and Clinics
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Last modification date: Wed Feb 21 10:36:06 2007
URL: http://www.uihealthcare.com /depts/med/psychiatry/research/registrationpanic.html