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208-497-0600

clinical research prime

Pediatric RSV

Birth – <5 years old
Participants will receive study related treatment at no cost and will be compensated for time and travel

Patient Info *

First

Last

Date of Birth *

Parent/Guardian Info *

First

Last

Phone *

Email *

Has child ever had a confirmed diagnosis of RSV? *

Did mother receive an RSV vaccine during pregnancy? *

Does child have a history of asthma or wheezing? *

Preferred Language

Please review my questions and contact me with further information for this study. *

I Agree

Adult High Risk RSV

18 years or older
Participants will receive study related treatment at no cost and will be compensated for time and travel

Patient Info *

First

Last

Date of Birth *

Phone *

Email *

Are you currently experiencing any cold or flu like symptoms? *

Do you have any of the following? (copy) *

Moderate or severe COPD with documented history of high exacerbation risk in the last year
Asthma that has required systemic corticosteroid treatment/hospital visit in the last year
Coronary artery disease requiring medication
Bronchiectasis
Congestive heart failure
Interstitial lung disease
Pulmonary hypertension
N/A

Preferred Language

Please review my questions and contact me with further information for this study. *

I Agree

Maternal RSV

15 month duration
Participants will receive study related prevention at no cost and will be compensated for time and travel

Patient Info *

First

Last

Date of Birth *

Phone *

Email *

Are you between 28 and 36 weeks of gestational age? *

Have you had more that 5 pregnancies? (Including miscarriages, still births, etc.) *

Do you have a BMI of <40 kg? *

Yes
No
Unknown

Preferred Language

Please contact me with further information for this study. *

I Agree

Senior RSV 60+

Men and women 60 years or older
Participants will receive study related treatment at no cost and will be compensated for time and travel

Patient Info *

First

Last

Date of Birth *

Phone *

Email *

Do you have a positive RSV infection confirmed within the last 3 days? *

Are you 60+ years old? *

Preferred Language

Please review my questions and contact me with further information for this study. *

I Agree

IDAHO FALLS

Monday-Thursday 8am-5pm & Friday 8am-2pm

187 East 13th Street
Idaho Falls, ID 83404

Clinical Research Prime is an Affiliate of Mountain View Hospital.

REXBURG

By Appointment Only
420 E 4th N
Rexburg, ID 83440

Call: (208) 497-0600
Text: (208) 508-1467
Fax: (208) 497-0606

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