Fields marked with an * are required.

First Name *

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Last Name *

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Phone number *

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Email *

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Date of Birth MM/DD/YYYY *

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ZIP or Postal Code *

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Are you Male or Female? * Please select one... Male Female Prefer not to say

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Are you interested in taking part in a clinical study for a new test for gonorrhea infections? * Please select one… Yes – I am interested No

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Do you believe you may currently have a gonorrhea infection? * Please select one… Yes – I believe I have a gonorrhea infection No

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Have you been exposed to a person with a potential gonorrhea infection? * Please select one… Yes – I may have been exposed to a person with a potential gonorrhea infection No

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Have you been diagnosed (by a doctor) with any other medical conditions? *
(For example: HIV, Herpes, Chlamydia, Trichomoniasis).
Please list here or write 'none'.
Please only include conditions which have been diagnosed by a doctor.

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Are you taking any medications for your Gonorrhea or other health conditions? *

Please list them below or type ‘none’. 

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What is the best day/time to reach you via telephone (we know you are busy)? *

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Would you like to be contacted about taking part in a Clinical Trial? *

Yes

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