About the Study
We are currently conducting a clinical research study for adults ages 18 years and older who have a wide lower face due to enlarged masseter muscles. The study involves approximately 15 visits over 12 months.
Do you have a wide lower face? Consider joining a clinical research study evaluating an investigational intervention to reduce a wider lower face.
About the Study
We are currently conducting a clinical research study for adults ages 18 years and older who have a wide lower face due to enlarged masseter muscles. The study involves approximately 15 visits over 12 months.
What are the benefits of enrolling?
This study is currently active but not accepting new participants. To be considered for similar future studies, please call our office at 586-286-7325 or complete the Clinical Trial Request form below.
NOTICE: HIPAA AUTHORIZATION REQUIRED TO USE THIS FORM. SIGNATURE FIELD BELOW.
HIPAA AUTHORIZATION. To the extent information in this form is protected health information under the Health Insurance Portability and Accountability Act, as amended, and its regulations (“HIPAA”), I authorize the use and disclosure of such information in accordance with this HIPAA AUTHORIZATION. I authorize the use and disclosure of all of the information that I have entered into this form (“Information”). I am the individual whose Information is included in this form or I am the personal representative of that individual. The purpose of this disclosure is to allow communication of the Information to a the medical practice from whose website I obtained this form. The Information will be disclosed to Dermatologists Of Central States and/or its information technology contractors (“Recipients”) in order to facilitate communication between me and the medical practice. I understand that I have the right to revoke this Authorization at any time prior to my submission of this form by simply not signing this Authorization, but once I sign this Authorization and submit the form, the Information will be disclosed to Recipients in reliance upon my Authorization. I understand that I am not required to sign this Authorization and that any medical practice making this form available on its website may not condition my treatment on whether I use this form to communicate with the medical practice. This Authorization has no expiration date. I understand that the Information used or disclosed pursuant to this Authorization may be subject to re-disclosure by the Recipients and will no longer be protected by HIPAA. I hereby acknowledge that I may print a copy of this Authorization for my records.
TYPE YOUR FULL NAME BELOW AS SIGNATURE AND AUTHORIZATION*