Intake Form – ReLateral

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Office

Weill Cornell Medicine
Division of General Internal Medicine
420 East 70th Street, 3rd Floor
New York, NY 10021

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Research Eligibility Screening Form

Name *

Name

First

Last

Email *

Phone *

Current Age *

Are you Latino/Latina or Hispanic? *

What’s your primary race/ethnicity? *

What state do you currently live in? *

What city do you currently live in? *

What is your current zip code? *

How long have you lived in your current zip code? *

Which days of the week would be best for you to participate in our study? Please select all that apply. *

Sundays

Mondays

Tuesdays

Wednesdays

Thursdays

Fridays

Saturdays

Which times of the day would be best for you to participate in our study? Please select all that apply. *

Mornings

Afternoons

Evenings

If you are human, leave this field blank.