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Research Regristration Form



AGREEMENT

By checking"Accept" below, you consent to the use of the personal information that you provide to Research Study Registry by Minnesota Eye Consultants, P.A. for the purposes described above. You also agree that Minnesota Eye Consultants, P.A. may use and disclose your information as described above.

You also represent and warrant that either:

  1. you are at least 18 years of age, and that you will enter only accurate information about yourself; or,
  2. you are registering someone who is not be able to register themselves (including individuals under the age of 18 or someone who is unable to register without your assistance) and you are the registrant's legal guardian, parent or legally authorized representative; you agree to the terms outlined above; and you will enter only accurate information about the registrant.

Tell us about yourself:

If you are registering for someone else, we will need your contact information as you will be the primary contact for this person.

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