The code block below illustrates how one might use # and // as comments in your logic and calculations.

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

iEHaesUsMzqJTw45kn9kPtY4AR5XwNbDxgp2brL3bcGCvEM9hTINfWidYMchdyadAra69hoRxEdwKH3m6k82hvduQA2hWeCyfw

General Screen Demographic Form

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Disclaimer: Information provided on the following forms will NOT be reviewed by research center staff until consent is given. By completing this form, you are agreeing to this information being held in the center's secure database. If you would like the form deleted from the center's secure database email us at arc@partners.org.

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Date:

First Name:	Last Name:

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CURRENT ADDRESS

Street Address	Apt #
City	State	Zip Code

CONTACT INFORMATION

Home Phone Number
Cell Phone Number
May we have permission to text you?
Work Phone Number
Email Adress

DEMOGRAPHIC INFORMATION

Date of birth
Sex assigned at birth
Race
Please specify "Other"
Ethnicity

EMERGENCY CONTACT

Name
Address
Phone# (Daytime)	Phone # (Evening)
Relation

Additional Contacts: Please provide the name, address, and phone #'s of 4 relatives or friends in the event we cannot locate you or your emergency contact.

	Contact 1	Contact 2	Contact 3	Contact 4
Name
Address
Phone #
Relation

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